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AS BUILT SANITARY SYSTEM REPORT
OWNER Vii, .ate/ X~S~Er° TOWNSHIP
I~
SECTION Z-:TN-R~W
ADDRESS 2l/~,~ Z' ST. CROIX COUNTY, WISCONSIN
1
` yo G✓C/
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
sz^ ~s ' /89 ~~rso~ 27-
7
f
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: z4azz z, l`
Alternate benchmark
SEPTIC TANK:Manufacturer: Liquid Cap. ¢
Rings used: - Manhole cover elev:1Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side, Rear Ft.~_
From nearest prop. line:Front Side_Z_, Rear Ft.
No. of feet from: Well ;2 , Building: /~y
(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
i
Bed: Trench: Seepage Pit:
Width: Length Z,2 Number of Lines:--~'_Area Built'2~z
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: Z:f
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
'Qiuon ril6epartme~{'o ncuET ry, 15 . 30.19 PRIVd►TE NW C. RD. S~EVI~AGE SYSTEMI County:
Labor and Human Relations INSPECTION REPORT
Safety aRid'Buildings Division ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
171503
Permit Holder's Name:
❑ City ❑ Village [Town of: State Plan ID No.:
EROSIER MICHAEL E & SUZANNE SOMERSET
CST BM Elev.: Insp76~ ~ BM D nption: Parcel Tax No.:
e_ Qs 032-2054-70-000
TANK INFORMATION ELEVATION DATA A9200268 d 3
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
'
Septic S e- Benchmarks 160,0)
Dos' • 6/ . 23
Aeration Bldg. Sewer 3. ,0..26
Holding St/V Inlet
TANK SETBACK INFORMATION St/Yf Outlet , F
Vent
TANKTO P/L WELL BLDG. A
irl to ntake ROAD Dt Inlet
Air l
Septic NA Dt Bottom
Dosin NA Header,-Merit.
7 X, • -?Wl i
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufi:i er ,C: Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To
SOIL ABSORPTION SYSTEM
BED / TRENCH width ! Length No. Of renches PIT o. is Inside Dia. Liquid Depth
DIMENSION DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O If-. Mo um er:
System: > ~g 1f OR UNIT
DISTRIBUTION SYSTEM
Header /-Fdoo 4eAtf » Distribution Pipe(s)/ x Hole Size x Hole Spacing Vent To Air Intake
Length _lg~t-l Dia. Length 7z- Dia. Spacing f0
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Ove S xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center
7j Bed /Trench EdgeVo "SZ Topsoil ❑ Yes ❑ No E] Yes E] No
16 -L
COMMENTS: (Include code discrepancies, persoris present etc
Plan revision required? ❑ Yes 2_1q,0
/
Use other side for additional information.
Date Inspector's Signatur Cert. No.
SBD-6710 (R 05/91) &:tiC
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
07B ILHR SANITARY PERMIT APPLICATION couNTY MEN In accord with ILHR 83.05, Wis. Adm. Code
ue,~wwuaw.e,r
r
STATE SANIT PERMIT#
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 / _C)
8% x 11 inches in size. ch k l e is n to pr a application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROPERTY LOCATION
'/4._ '/4, S T_ G' , N, R E or
PROPERTY O E i'S MAILING ADDRESS LOT # BLOCK #
f
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION 7NME OR CSM NUMBER
r 7 ~s
11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE : NEAREST ROAD
❑ Public M 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX N )
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 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. X New 2. ❑ Replacement 3. ❑ 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 M 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
C S iV C ' Feet : "Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank c!"
Lift Pump Tank/Si hon Chamber El I El El L1 1 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installatio of the onsite sewage system shown on the attached plans.
Plumb is Nam (Prf t):l Plumber's ig ture: No Sta +i MP/MPRSW No. Business Phone Number:
J S
Plumber; Address Street, City, State, Zip Pod?):
XY /Sny- /In~- __S> /~w_
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit FAe (Includes Groundwater Date ssue issuing A ent Sign S
,4T'Approved ❑ Owner Given Initial urcharge Fee)
Advers1p rmin tion
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 -eneHal 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 (S`?D 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be puinped 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.
11. 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, purnp/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 thn ccunty. The
plans must include the following: A) plot plan, drawn to scale or with complete dimenr.ions, location of
holding tank(s), septic tank(s) or other treatment tanks; bull=ding sewers; wells; water rnainslwater service;
streams and l,ikes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal a cl vertical elevation refe.renCE' points;
C) complete specifications for pumps and controls; dose volume; elevation differences fric i-)n loss; pump
performance (,;rirve; pump model and pump manufacturer; D) cross section of the soil ;lbsor,rtion 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 numl✓=-:r of
regulated practices which can effect groundwater.
I
The mogiies coll:, cted through these surcharge,-) arc, used for monitoring groundwater, ground-
water c onlarnination investigations and establishment o' standards.
SBD-6398 (R.11/88)
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 c, 51
Location of proPertY~ 1/4
S X 1/4, S e
.Lcoon '.1 T_10 N -R r ~W
.Township r" e V 5
Hailing address
Address of site
Subdivision name Lot no.
Other homes on property? yesNo
Previous owner of property
Total size of parcel 4 0~)
Date parcel was created -
Are all corners and lot lines identifiable? ~ _Yes No
la thia property being developed for (spec house)? Yes 4--No
Volume-960 and page Number -11X as recorded. with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE rOLLOWING:
A WARIUUI1'Y DEED which includes a DOCUMENT NUliBER, VOLUME AND PAGE.
HUMBEIR & THE SEAL OF THE REGISTGIt 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 Maps the certified survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(wc) certify that all statements on this form are true to the
best of ny (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No.
~,5q kq , and that I (we) presently
oo:n the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in lie office of county Register of deeds as Document
No. _~5~1n y
Signature of'ap~licant ~ C appl cant
e
'7 --7
Date of Signature Date of Signature
T ~J
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d H lam';.
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER C D I ~ 1^
ADDRESS C o T FIRE NUMBER /S
CITY/STATE IV I ZIP 5'q4 z S
PROPERTY LOCATION: ~W 1/4,S 1/4, SECTION 15, T-3-0-N-R-LI-W
TOWN OF w► c rSc t , St. Croix County,
SUBDIVISION , LOT NUMBER
Improper use and maintenance of your septic system could
result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three
years or sooner, if needed by a licensed septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant
for a maximum of 600 of the cost of replacement of a failing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1) the on-site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning officer within
30 days of the three year expiration date.
SIGNED•
DATE:
7 ' 7 Z
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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