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AS BUILT SANITARY SYSTEM REPORT
OWNER 4oAS ~o• ~ti c. TOWNSHIP //a/-~Soal
SECTION-,L _T Q N-R~ _W
ADDRESS , ~9 2 24A2M47a47 / Tyr ST. CROIX COUNTY, WISCONSIN
SUBDIVISIONsi 0^.,.'x l~~•ui-a//~s-,~ZO- Rife LOT g LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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SD? 3S E-rlkI- Vr NC -~FNt
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INDICATE NORTH ARROW
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L~.sv 9a/•~/BENCHMARK: Elevation and description: W1, A fo CeosSs-v 5
~ 7,,~,j,a< /CSC
Alternate benchmark 7n//9. 7S w mow oo~ !fir- 090nO ,eTt- Cv,P ue r
SEPTIC TANK:Manufacturer: GJ,--'S Liquid Cap. ,/000 42v(,-
Rings used:( Manhole cover elev: / 9V Final grade elev:'
J'l-'!5 '
Tank inlet elev.: /3. 25 Tank outlet elev.: 9/3-00-
No. of feet from nearest road:Front , Side , Rear ✓Ft. 7'
From nearest prop. line:Front , Side , Rear '--Ft. No. of feet from: Well 5.2' , Building: /9-1
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I~
i
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•44v. 9Trench: Seepage Pit:
Width:-/V' Length 33 ' Number of Lines : ~ Area Built S941s-e•
Exist. Grade Elev. '7/G• Proposed Final Grade Elev. 9/5~ 9 S `
Fill depth to top.of pipe: Q-yS"
No. feet from nearest prop. line:Front , Side f, Rear Ft.-y4 '
No. feet from well: SV' No. feet from building y4`
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:c'
/ J
1
LOCATION: HUDSON,8.29.19,NE,NE,SCHOMMER DR., LOT 8
11
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
`Labor and Human Relations INSPECTION REPORT
Safety and-Buildings Division ST. CROIX
` - (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 149335
Permit Holder's Name: ❑ City ❑ Village)] Town of: State Plan ID No.:
MAPCO GAS PRODUCTS INC. HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
020128580000
TANK INFORMATION ELEVATION DATA A9200181
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 7Z 919 P,-,
Do r 915, O
Aeration Bldg. Sewer
Holding St/ [;Wlnlet 3 6
TANK SETBACK INFORMATION St/ IR Outlet
TANKTO P/L WELL BLD#G. ROAD Dt Inlet
Septic NA Dt Bottom
A Headers 0 1912, 77 1
Dosing N
Aeration NA Dist. Pipe 98/, G
i
Holding Bot. System 703
PUMP/ SIPHON INFORMATION Final Grade
Man r Demand o~- S' c,„,~ / 7, 7<) 7
Model Number GPM
TDH Lift Friction System DH Ft
oss mead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length r No. Of Trenches PI o. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /y, I 33 DIMEN 1 N
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING anufacturer:
SETBACK r
INFORMATION Type O c CHAMBER Moe Nu
System: ✓ ~ / y0 OR UNIT
DISTRIBUTION SYSTEM
Header hhan+feld Distribution Pipe(s) r r x Hole Size x Hole Spacing Vent To Air Intake
Length ~02 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 a5 - 2 Topsoil C] Yes C1 No E] Yes E] No
,116 COMMENTS:
/ (Include code discrepancies, personas present yetc.)
Plan revision required? ❑ Yes 2_K_0
'r 7 g l !
Use other side for additional information. ~ 71 1
SBD-6710 (R 05191) Date Inspector's Signature Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
T DILHR SANITARY PERMIT APPLICATION
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 C? c ~/G 017 3
8% x 11 inches in size. ❑ C eck if revision to previous appl ti
-See reverse side for instructions for completing this application. .;WE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
S ,5 j T N, R E (or) W
PR61PEKTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
_r7- /a
L:I II. TYPE OF BUILDING: (Check one) ❑ State Owned 13 VILLAGE NEAREST ROAD
! 4
4OWN OF: S Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo oC v s
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 OK Office/Factory 13 ❑ Other: Specify
IV. TYPEOFPERMIT: Check only one in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ 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
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
cam/ J~'(,i J_,9 y , JK < Feet . Gt~Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank /000
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:
qAx_,)A Z4 C, Plumber's Address (Street, City, State, Zip Code):
,
It COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Is g Agent Signatur No stamps)
Approved El 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 B 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 Wi§consin 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 yourlocal code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
Il. 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. X
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 a//.
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DII_HR.
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. X
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, ocation of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water maairs/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; rppla.emer•t 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; fri(.,i :)n 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 rnonic:s c:oilected through these surcharges are r.rsed for rPonitoring grOUridwater, ground
water contamination investigations and establishment of --tandards.
I
S8 D-6398 (R.11/88)
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
,INDUSTRY, USTRYUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNS I P/LOT NO.: BLK. NO.: SUBDIVISION NAME:
8 S, Irv~s~-c ldc aak
N E 11 Mil N/R / E (or) W 4 Isbrq
CO NTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
i CRo JX /J v ~o
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: 9 New DES PTIONS: PER ATI N TESTS:
1~JNew ❑Replace Z& 9z 29 9Z
'Sol
cs K 'SFS ) - $x_~N,~ ~2 d7-
RATING: S= Site suitable for system U= Site unsuitable for system
rJ4J run ONVENTIONAL . M~ . IN GWS P❑~ RE: SY EM-INFILLHOLDING TANK: REC~gxjV&,V-r S/a4 AoZptio 154.4
~
SS ❑UU EIS (I~I~JJrU ~
If Per colation Tests are NOT required DESIN RATE: I If any portion of the tested area is in the A/4
under s. ILHR 83.09(5)(b), indicate: LgSS / Floodplain, indicate Floodplain elevation: IS G CV- r PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 1jt ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 ob 9i~ o~ .ao 1248L5,t--s /6"BeNS~L2s~y$+2,.►IM.j~4Q~fa~D
Z "BLS, STS 22" aNS, L 23 ¢N►'►1 Gre Go
B- 16,06 917.26 /b.oo i3"Rbes-44,e -Se ae'j A1.5 -Pe. 6
9~ .37 > lD.7S /s $ts,~~5 /6"$eNS,Lza QuMS rf4e7ts"$aNMS~4+t
B-3 1635
B- 4 o% 9/01 t4t) ri a- ? ,p )3"BLS)L75 /8'~$aNs) L 9e8@,vAi<4e
> 6 z3''8zs,l.TS i4"$aNS,~ 7~"6a,~ ~S~r~ IR
B- .06 91-7.47 Atoljf
B_
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER JAW4M AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 P R PERINCH
P- A< 140,41F !740 3 > 2 > 2 > -Z
Kp'4
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)1. o > >Z > 7 O Le Z Z P_ 0IJ A-7
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.
1.75
SYSTEM ELEVATION
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ELiV+aT1CtJ7 495
9
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the gQcedu sand methods specifieci,in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowled a elief. 4]LftO
''m' G'RO~S )
NAME print): TESTS WERE COMP ETE ON:
~O NSo~J ..~NUSOU Sv~LV ~nJ4 4 z9 914
ADDR SS: CERTIFI TION NUMB R: PHONE NU BER(optional):
Dso>J I~✓~s~>v3,~, S4c>>6 3%448'6
STS ATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS EOM` ~ ETIN FOND 15 - SRO - 5395
To be a cc ~ te arid acew ate soil to r ;)oI't mus
1. Compl ' scritation;
2. The use r °tust clearly indicate tl is is a rep idr twp or- commercial pio}ec.t;
3, RfiAXlit!" : ` ,,.,r of beclioorns or ; use planned;
4. Is this a it :nt cyst
. C;om;>l y rating b "'JITABLE FOR A F-DI.DING TANK ONLY IF ALL
£3TH= .3.= UL-L- SOIL CC. NDITI'
. PLEASE c a g profil, c'le~ rls and compl ing the plot plan;
. 1141AKE A 1 pace nur ` .:)i'awing to preferred. A
separate she d~>s
8, (hake sure ; nd v l `ej errce p= r~ =arly shown, ai J are permanent;
9. Complete all boxes as i, aes, address( rata, percolation test exenlp-
tion, it p
10} tf the iEnforfTIZ- Al (SUCK as food tion) does 't, it) the appropriate box,
11. Sign the form ar<d place your cu, ss and your cetr, „
12. Make legible copies arlcl distribul ~i, ALL SOIL . 3TS ;u1LIST BE FILED WITH THE
LOCAL AUTHORITY MTHIN 30 L -.Y ~I'LFTIW
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Snail Separates and Textures mbols
St: Stogie (Over 10") BR -3edrock
cc[) Cobble (3. 10") SS Sandstone
gr Gravel (under 311) LS t astone
Sahel F { --aeandv ater
P "ran Rate
s Caa°se Sand
med e5 Medium Sand
dine? Sand
Is anly Sand J
- x.sl -t,y Loan) ~ -
- 5.. Y
Sic,? LCMM rnol
sc r C "y v; .
sit: Silty Clay fff faint
kC GC :3or?, Coarse
1 mrn , mediUM
l ck d
P t~
IR'"_ High . u
sste c <a Bench IS
`kfFVe, erence Point
t
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.
I
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER /A /Q c o t" e( C
ADDRESS : I ~1 G 1__ FIRE NO :
,H -V
LOCATION: / 1/4, 1/4, SEC. T_,2U_N-R_,Zj W
` r
TOWN OF:. v L) S(~ ST. CROIX COUNTY
SUBDIVISION:s 17': CAya_x LOT NO 17C_
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 to
help with the cost of the 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 the St. Croix County
Zoning a certification form, signed by the owner and by a master
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. Certification from will be sent approximately
30 days prior to three year expiration.
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 form must be completed and returned to the St.
Croix County Zoning Officer within 30 days of the three year
expiration date.
SIGNED
l~ DATE: _ L/
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
STC-100 .
This application form is to be completed in full and signed b
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.,&C 1/4 , -1/4, Section -
~ T&? N-R_ZZ W ~
Township
Mailing address
Address of site
Subdivision name ES
T rl / 1'TnT n ~ ~,Ot no • _ ~ .
other homes on property? es
Y __-L___No
Previous owner of property
Total size of parcel
c
Date parcel was created
i
Are all corners and lot lines identifiable?
Yes
No
Is this property being developed for (spec hour
e ?
Yes
_2!~No
volume and Page Number as recorded. with the Register
of Deeds.
INCLUDE WITH T
IiIS APPLICATION
A WARIUVITY DEED which includes aDOCUMENT ENU2iDER, VOLUME AND PAGE,
NUMBER & THE SEAL or 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 ce
shall also be rtified 3u
required rVe Map
y PROPERTY OWNER CERTIFICATION
I(we) certify that
best of n all statements on this form are true to the
y (our) knowledge that I (we) am
the property described in this information form, bthe owner( y virtue sof oa
warranty deed recorded in the office of the County Register of
Deed, as Document No. and oo:n the proposed site for the sewage di p salt system, orr es e(we)
obtained an easement, to run the above described rt, for
the construction of said system, and the same haso been duly
r
ecorded in the office of County Register of deeds as Document
No.
Signature of ap~ll t
Co-applicant
Date of Signature
Date of signature