HomeMy WebLinkAbout020-1085-90-000
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ARTTHUDSON T29N.-R.20-19W 25
SEE PAGE 99
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Pev /979
R.20 W_ _<_-R.1-9 w.
GILBERT QUALITY ALFALFA
& SOYBEAN SEEDS
MOTORS INC.
MELVIN VOLKERT
Allis-Chalmers New Richmond
ALawn & Garden 246-4118
Tradition ~ •
Equipment Open Years n Daily SO of at 111::3 3 Dining a.m. For
For ~ ~~y
- RUJAN
Pontiac & Olds Luncheons, Cocktails and Dinner T
PNONu 247-3305
Sales & Service Toll Free From SI. Poul-Mi Minneop
neopolis 439-7710
the e Trip River
Phone: 386-5155 Heodqua nnerFTub
Hudson, Wisconsin 11/2 MII•• E■st ■f SOIn■f••T '
Highway 44
J
i •
• AS BUILT SANITARY SYSTEM REPORT
ER Jame, , TOWNSHIP u d ~SEC.3n_ TLN R % W
ADDRESS , ST. CROIX COUNTY, WISCONSIN. 21 LIB
:;DIVISION , LOT LOT SIZE
PLAN VIEW - ; c) v 1 -
Distances b dimensions,,to meet requirements of H62.20@~.~0'r~~ti~L`~
SHOW EVERYTHING WITHIN 100 FEET OF SY TEM
e e
Ay I
i
u"-
r I
I
I
Iridi, ate No th A ro
l3.i SC L O
:TIC TANK(S) MFGR._ CONC STEEL
NO. of rings on cover Depth DRY WELL
:_NCHES NO. of width length area
no. of lines, width length ,2j0, area
,
1/epth to top of pipe
,,.ELATE c/
' RATE / AREA REQUIRED AREA AS BUILT
;giaimer: The inspection of this system by St. Croix County does not imply complete
.,,oliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
:;_em operation. However, if failure is noted the County will make every effort to
`ormine cause of failure.
'::'USES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
'-INSPECTOR
DATED 3-16- '7e PLUMBER ON JOB
LICENSE NUMBER
.I _
REP-ART OF ITISPECTIO?T--INDIVIDUAL SEWAGE DISPOSAL, SYSTEM
F
Sanitary Permit
TIC ate Septic
TOWNSHIP
t. Croix County
'J YI
TIC TA'?I: '
Size gallons. `umber of Compartments
• Distance From: Well
ft. 12% or greater slope ft
Building' ft. Wetlands f:
Highwater ft.
DISPOSAL SYSTMI Tile Field or Seepage Pit(s)
Distance From: We~ ft, 12%.or greater slope" "9S f t
Building -`--ft. Wetlands
FIELD Righwater ft.
Total length of lines Left. Number of lines`. Length of
each line Q -ft. Distance between lines to ft. Width of the
each L_ft. Total absorption area sq. ft. Depth
qaof rock -below tile f in. Depth of rock over tile in.. Cover
ver.rock., Depth of tile below grade Slope of
trench in er 00 ft. Depth to Bedrock - ft. Depth to
Around water /£t.
PITS
Number of pits is de i meter ft. Depth e o let
ft. Gravel arou p t: es no. Total absorpti area
sq. ft.
.Square feet of Leepage tre ch bottom area required
:square feet of are required - -
Inspected b' Title':.
Approved Date -_19714
Rejected Date _197-.
l~ ,
~ J.~.~~ J
EH .11
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
-REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION:~'C %,/Vl Section , TZ_LN, R)T 111(or) W ownship r Municipality Lot No. , Block No. County :s:r. C- r X
Subdivision Name
Owner's Name: S0. m c~•~ ~'tr-, h A r jcu,'I
Mailing Address: ~lyIS~'~ S/G!(>
TYPE OF OCCUPANCY: Residence ✓ No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT ll
DATES OBSERVATIONS MADE: SOIL BORINGS-7/ -_;l/-7 ES PERCOLATION TESTS ZF r 7g
SOIL MAP SHEET = ( I' N IZq- SOIL TYPE A n!Gc, ~
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- ul Z I L oCt i'Yl 5c~ v~ t-{ 78 LI L(
u j
P- Z rr 2 Z( i t ~ _ oc:c VV% s.4 4 Ilya
3S 141 Al 0 t4 ip
1 A)6 A
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B_ > q ' V b a e, L. L at (c O
B -3 LI L V,
Cl it a3tt w.n C
a it 2-4
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suita4le areast Indicate number of square feet of absorption area
needed for building type and occupancy. b Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
t.u e l
5LE44 N,
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19 POO
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1, 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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) A Ile 1cc.`e 4 ; YNI `k Certification No. ~
Address ~CD.l Gt~
Name of installer if known
CST Signature
COPY A -LOCAL AUTHORITY J
PL867 State and County State Permit
Permit Application County Per
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: % /n/t Y4, Section 3v , T Q? N, R J4 (or) Q Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
I Township SO
C. TYPE OF CCUPANCY: Comme ci I *Industrial *Other (specify) *Variance
Single fam X Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder_)!( YES NO # of Bathrooms
Automatic Washer K_YES NO Other (specify)
110.
E. SEPTIC TANK CAPACITY /&00 Total gallons No. of tanks /
*Holding tank capacity Total gallons , No. of tanks
New Installation -Addition- Replacement _ Prefab Concrete X
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2► / 3) -/Total Absorb Area Gy$ sq. ft.
New 9 Addition Replacement *Fill System ws "elepirecc
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length 3&p Width /9" Depth 'Y O"v Tile Depth 284 No. of Lines 3
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land M Distance from critical slope-'7,7'
n SM s- ~-t~ I~r~ec~
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME - C.S.T. # and other information
obtained from clftes -71 nA- (owner/builder).
Plumber's Signatures Z MP/MPRSW# -P'9 Z3 Phone *&L-!59
Plumber's Address M S O C= S 4 0 1 tm
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well). /V nr c
~ J
S
L:103'
rv Well
YOO o v
Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application Fees Paid: State/C_ oa Count Date ~--Z~
Permit Issued (date) - Issuing Agent Name
Inspection Yes4No Valid# Date Recd
1. county (white copy) 3. owner - (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76
AS BUILT SANITARY SYSTEM REPORT
OWNER James T. Johnston TOWNSHIP Hudson
SECTION 30 T 29 N-R 19 W
ADDRESS 762 Carmichael Road ST. CROIX COUNTY, WISCONSIN
Hudson, WI 54016
SUBDIVISION LOT 1 LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L I [1615 E
N
D Iz IV e W'4y GARAGr loo' PVcG
4
v~IELL
GSA N n~s
(pO
o~ 1
1540 GAL. SE'PTIc
WIESeR.
P
PVL
CE ms l<t
~,LDG. S~aB~ RM
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: EL 100.0' on Concrete Floor
Alternate benchmark
i
SEPTIC TANK:Manufacturer: Wieser Liquid Cap. 1560
(10-- a6211 )
Rings used: 3 Manhole cover elev:5z" Final grade elev:511" (9611111)
(97211)
Tank inlet elev.:4-Tank outlet elev.: 5154" (96'6211)
No. of feet from nearest road:Front , Side , Rear90 Ft.
From nearest prop. line:Front100,+Side , Rear Ft. 100'+
No. of feet from: Well 80' , Building: 50'
(include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
t
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: 3 Seepage Pit:
Width: 5' Length 67' Number of Lines: 3 Area Built
Exist. Grade Elev.5'2" (96 1 Proposed Final Grade Elev. same
Fill depth to top of pipe: 32"
No. feet from nearest prop. line: Front 1001'-4Sid420', Rear100 ,
No. feet from well: 90' No. feet from building 100'
HOLDING TANK
Manufacturer: Wieser Capacity: 1560
No. of rings used: 3 Elevation of bottom tank: 9191-;," (92'24%11)
Elevation of inlet: 4'1114" (97,")
No. feet from nearest prop. line: Front1QQ',+ Side100',+ Rear100'Pt.
No. feet from: Well 80' , building 50' , nearest road 90'
Alarm Manufacturer:
INSPECTOR:
DATE: May 11, 1992 PLUMBER ON JOB:
LICENSE NUMBER: MPRSW2739
6/90:cj
LOCATION: HUDSON 30.29.19.345D,SE,NE, CARMICHAEL RD.,LOT 1
•
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor- ro Humlin Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 149324
Permit Holder's Name: ❑ City ❑ Village)Cl Town of: State Plan ID No.:
JOHNSTON JAMES T. HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
020108590000
TANK INFORMATION ELEVATION DATA A9200171
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~-(o~ Benchmark ,61V l00
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet lf4~ ~Nj(~0~
TANK SETBACK INFORMATION St/ Ht Outlet l0/ 6
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air Ito
/bD g D 570 ' >SO NA Dt Bo om
1. 9 17
Dosing NA Header / Man. 3~ qg, v~
5i. 23 97, sri
Aeration NA Dist. Pipe T 3 43.9
7- ~ C 0A -7'7
Holding Bot. System ~gq 9°•6'
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand , 6 /o4,,, 5
Model Number GPM
TDH Lift Friction System TDH Ft
Loss 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 1O 7 3 DIMENSIONS
LEACHING manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
/
INFORMATION TypeO CHAMBER Model Number:
,yW y/Da • /oo ' fD N OR UNIT
System:
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 a 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 I specto 4 Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILH SANITARY PERMIT APPLICATION . COUNTY
...a. ILHR In accord with ILHR 83.05, Wis. Adm. Code
St. Croix
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than / ?
8% x 11 inches in size. 1:1 check:5rrev ion to pre ous 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
James T. Johnston SE X NE S 30 T 29 , N, R 19 XXPQ W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
762 Carmichael Road 1,Vol 4 CSM pg 975
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Hudson, WI 154016 i(715 )386-532
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) State Owned o
M TOWN OF: gjjr1§r)n TILLAGE Carmichael Rd.
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms NUMBER(S) -4- PARCEL TAX III. BUILDING USE: (If building type is public, check all that apply) 020-1085-90
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. El New 2. ❑X Replacement 3.E1 Replacement of 4. ❑ 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 10 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 SYSTEM EV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
600 1005 1005 0.6 Class 1 1 et Feet
VII. TANK CAPACITY Site - -
In allons Total #of Manufacturer's Name Prefab. Con- Steel, Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank X Wieser
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): P 's Signature: Stamps) MP/MPRSW No.: Business Phone Number:
Paul R. Cudd I MPRSW2739 715 425-2049
Plumber's Address (Street, City, State, Zip ode):
1047 S. Wasson La., River Falls, WI 54022
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S tary Permit Fee (Includes Groundwater Date Is ue issuing A nt Signs o S ps)
Approved El Owner Given Initial / Surcharge Fee)
Adverse Determin ion
X. CONDITIONS OF APPROVAL./REASON R DISAPPROVAL:
SBD-6398 (for erly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
i
INSTRUCTIONS
1
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 (SI3D 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 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 mainsiwater service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
i
SBD-6398 (R.11/88)
i r
r ~
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 a ?n e S 7 ~o
Location of Property Section , T7N-R~ W
Township U d 3 d
Mailing Address
Address of Site S itl~ e
Subdivision Name Va. ~ ~ - 2
..;;Lot Number
Previous Owner of Property X tai c~,r
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 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, and 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
1 (we) ceAti.by that a.U statements on thi.6 bonm ane true to the best ob my (oun)
k.nowtedge; that I (we) am (ane) the owner(s) ob the pnopelcty dacA bed in thi.6
.inbonmati,on bonm, by viAtue ob a wannanty deed neconded in the Obb.ice ob the
County Register o6 Deeds as Document No. 7'7 ~1 and that I (We) pne~s entty
own the proposed .bite bon the sewage d,&5poaae by6tem (on I (we) have obtained an
eaaement, to nun with the above debchibed pnopehty, bon the constnuWon o6 said
system, and the same has been duty neconded in the Obb.ice ob the County Regizten ob
Deede, as Document No.
S ATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
r•i
F ,y
All" Asmila
Aw of STAU Or
ooM ~r~
July 179
~R 0! ~lp0i~l[t _ ~
7, 7%
e
b
to or koamm to be the
F ,
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olb fR Md R 01 BDlk ~Oh" • It
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SEPTIC TANK MAINTENANCE AGREEPIENT rt
St. Croix County r
a
OWNER/ BUYER a 7;, c 7- Jd' rr 7 fi o
~C ROUTE /BOX NUMBER a C. Fire Number
CITY/ STATE ~y c' ' e T7 i S ZIP 5i L/ rr / M
PROPERTY LOCATION:,/Section T `N, RW,
Town of 4d , , ~ f ari, S t. Croix County,
P
?
Subdivision Nl a'~~ 7=~ Lot number
Improper use and maintenance of your septic system could result in
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 licens*ed''sept'ic_tank pumper. What you put into
the system can affect tie-funct on o. the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix Count residents may be eligible to recieve a grant for
a maximum of 60K of the cost-of replacement of a failing system,
whit 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 County Zoning a
certification form, signed by the owner and by a mater 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
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 Depart-
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration. date.
SIGNED_
T
DATE
St. Croix County Zoning Office T`
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
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Owner's name San. Permit No.
H63.05 PLOT PLAN
Show:
E Location of building served MA Dosing chamber
Septic tank Q Vertical/horizontal reference point
.I st Or~r,w~
Building sewer System elevation is OvRwG C.O+J51RUCVOrv
E ` Effluent system Q Well
ED1J-A Replacement system area N.q Property lines w/in 501 of system
Distribution boxes j Scale = \"=q0' , or dimensioned
N•A - Pump and controls:
Mfr. & Model No. Vertical Lift Size Force Main
Friction Loss T. D. H. Vol. Dist. Pipe Ga1..per Hit. Gal. per Cycle
Place check mark in appropriate box, indicating item is shown on plot plan,below:
4 9 t4?-M
~t Restfl~~8
CTXIS~ty C
sepn e ra -
% BE 1Brtwa~.
F'iS PL'ct eoDE .
w~ x c-~3'hN oc~ T
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o
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a
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s ~..so GqL_, w~es~
cvjn'- s@PT1c Tfr k
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/
81 06 . S O/ / / 1.vilSS ~R OOh/ CRCTTI
i ' Q13112\@uTtoN fox
Br'1 - ~ . LOO.O oN S ~ j ~ e-t
Fwo R / to
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z Zc °ln
By the granting or approving of the ve plan, or upon the event of a subsequent
permit being issued, St.CroixCounty and theSt.CroixCounty Zoning Administrator, does
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
s
after installation.
MPnsw' A73
P um r ssicna re iLIeW ice-' Date
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• V Jul] .
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p1 M PrAjb 2" C)F
Tc~.~►e~1 ~l..~v~olt►s 'to DE'F1=1Z~~/~ gr,6REGhTE ~eo~~ PIPE.
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