HomeMy WebLinkAbout032-1016-95-000
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DEPARTMENT OF REPORT ON SOIL BORINGS_ AND SAFETY & B DI
INDU VISION
STRY, -
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
HUMAN RELATIONS
N WI 3707
HUMAN
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNS HIP/M£l TY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
E 1/4 NE 1/4 6 /T 31 N/R19~X(or) W Somerset 18%2 n/a Grace Development
COUNTY: -OWN ER'S/@bti¢AME: MAILING ADDRESS:
St. Croix Ronald Jorgensen 112524 Quail_ Hay IT., `>tillvater, PTn. 55082
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Eip esidence 3 n/a {New ❑Replace 3-10-92 13-10-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
El U BS ElU E:]U S gu S conventinal
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 1 OND2
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B_ 1 7.58 100.45 none >7.58 .83 7.5yr3/2 s.l. 1.757.5yr3/4s.1. 5.00 7.5y/r 4/
C.S.
B- 2 7.00 100.50 none >7.00 1.00 7'S .l. 2.00 lsil. 4.00 7. Syr C4/4 ,S.
si]_
3 7.66 99.50 none >7.66 83 7.5yr3/2 1.08 7.5yr3/4 7.5yr4/4
B- . s.l. s.l. 5.75 C.S.
4 7.01 97.20 none >7.01 .92 7'syi3/2 1.17 7S.l. 4 4.92 7.5yr4/4
B- C.S.
B_ 5 7.08 96.70 none >7.08 .33 7.5yr3/2 1.17 7.5yr3/4 6.00 7.5yr4/4
s.l. s. c
B-
decimal' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER D PER INCH
p- 1 3.95 none 3 6 6 6 <3
p- 2 .00 none 3 6 6 6 <3
P_ 3.00 none 3 6 6 6
<
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 96.50
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3
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OZ~ N r^
n the Wisconsin
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with t A roce~d*~and.+x~eth spec
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my kn %s, a belief. _s
m N
NAME (print): TESTS W ETED
Gary L. Steel 3-10-9 C Z
ADDRESS: CERTIFI I N NU BER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Wi. 54017 7,;5-2a-6200
CST SIGNA R
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
J
•
11- -TION 7~ 'ONIPLETINC ° 15 - I - 5595
To be a cu to :E your report must
1. Corr, on,
2. The u . = s e i ly '}other this is a ~ comn~e€ ject;
3, MAX1"l bed€o r, nr iorciai d ;e [)lam
4. Is this -''It sy
S. ta'ing .SITE I s SUITAI~ O A HOLDING TANK ONLY IF ALL
? RULE[ BASED ON SOIL ~ 'ITIONS;
'at.jons sr for writing profi s riptions are completing the plot plan;
i_ am Ey IOCatirg Your test ' ations. D5,av ing to scale is pref€.=,r€ed. A
S, P .ke 7c! alevat c~= refere ne re clearly shown, and are permanent;
9. C :€n boxes 'aces, nar7es, aC ' `food pl< in percolation test exemp-
ti
10. If tt. "evation) do--3 ~ plan- I the appropriate box;
11. Sign tj~ your cc, ess and your c, ~.on nc ;
12, Make lei . and distrif, requi€pd, ALL u TESTS f_UST BE FILED WITH THE ~
LOCAL y Y WITHIN :3 DAYS OF COMPLETION,
3 A' IIATION FOR CERTIFIED SOIL. :R S
Soil Sc a and Textures othe<
st_ -'r 10"j BR
cob - C _ 10 - ) SS
qt. nder 3"j LS
s 'ter
cs - C F_ to
med s sil - Si L€3a!n 3 k
a: t ~ ary3
! r,o'tle5
~y - wiIh
a sit. 'Aly Clay f fete, fine- -pint
com....-r r4` e 1
P Man, rr m
M .~ck - distinct:
I promine"
High vv
Si, ~il t" Ski
s B -ch l
V Ve€ ti ice Pont
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION LABOR A HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON W 7969
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS H I P/Mi~TY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
r /NE1/ 6 /T 31 N/R1910or) w Somerset 18%2 n/a Grace Development
COUNTY: OWNER'S ~cME: MAILING ADDRESS:
t. Croix Ronald Jorgensen 112524 Quail Way N., Stillwater, P'n. 55082
USE DATES OBSERVATIONS MADE
NO. BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE DES RIPTIONS: E~- A~QN TESTS:
~esidence 3 n/a New ❑Replace 3-10-92 LL
6=1-s12
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S ❑U S ❑U ® S ❑U ❑ S EiU ❑ S ®U conventional
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/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B-6 $4 96.02 none ~g4 0-8, 10yr4/2; 8-18, 10yr5/4, s.sil.; 18-29, 7.5yr
4/4,s.1.; 29-84, 7.5yr4/6, Co. S.
0-8, 10yr4 2, 1.; 8-16, 10yr5 4, sil.; 16-30,-
6.7 84 95.12 none >84 7,5yr4/4, s.l.; 30-84, 7.5yr4/6, Co. S.
g_8 96 98.42 none ~g4 0-10-, 10yr4/2, 1.; 10-22, 10yr5/4, s.sil.; 22-
B-8 4/4 s.l.• 28-96 1 5/6 Co. S.
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER 100 PER INCH
P-1 4.30 none 3 6 6 6 <3
P-2 3.40 none 3 6 6 6
P-3 2.50 none 3 6 6 6 <3
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 94.32 ~k
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I, the undersigne e y ce 19 t e soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisc nsin
Administrative Code, an ata recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Gary L. Steel 6-4-92
HONE NUMBER (optional):
ADDRESS: CERTIFICATION NUMBER: ~15,,x946-6200
1554 200th. Ave., New Richmond, ti~i. 54017 2298 CST SIGNA
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
L
1P'- RUCTIONS FOR COMPLETING FORM 115 - BD - 6395
To be a cc and accurate soil test, yoarr report must include:
1. Complete I cription;
2. The use s,' -gust clearly indicate whi r this is a residence or commercial project;
3, MAXIMU . per of bedrooms or coin cial use planned;
4. Is this a nr ' A -nt system;
S. Con,^I-,= rating boxos. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
O_ :RE RULED CJT BASED ON SOIL CONDITIONS;
6. PIL "eviations i here for writing p€ e descriptions and completing the plot plan;
7. M/V L- diagram tely locating your locations. D -ving to scale is preferred. A
A ?d i { ' f,:; -
8. _..nark and elevation ref. point arand are permanent;
9, Comp ~ riate boxes . ~ tes, names, flood PL, lation test exemp-
tion, if e;
10. If the '(Irmat.ior7 (such as floc , elevation) dcs m )ply, place N.A. in the appropriate box;
11. Sic. ti -i and place your cur- . !dress and your ce Jior) number;
12. Make copies and distrih re(Juired. ALL TESTS MUST BE FILED WITH THE
LOCAL ,UTHORITY WITHIN , )AYS OF COMPLET 9N.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - ! 'w-, rn_-r 10") BR f oc..k
cola - Cc ' - 10") SS - a; 'le
gr - Grd ter 3") LS - Li o~1e
- Sand H G W - F ru
Coa i Perc F )n s
Fine Sa ;i Bldg -
is L any Sand Than
sl - 'y Loam _ I TI an
Il Bn
sit L .ara~ BI
si - Gy t,
y Loam Y
R - I
Clay
I
P - pry
} _r ' 'xtureg
a d,sposal
VRP
t
TO THE
Is t< :1 a#. y C I 1y t
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Parcel 032-1016-95-000 09/12/2005 05:00 PM
PAGE 1 OF 1
Alt. Parcel 6.31.19.85J 032 - TOWN OF SOMERSET
Current rX] ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
JUDITH G FRENCH O - FRENCH, JUDITH G
2363 DELONG RD
OSCEOLA WI 54020
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
z~
SC 4165 SCH D OF OSCEOLA
SP 1700 WITC
~ l l
Legal Description: Acres: 2.800 Plat: N/A-NOT AVAILABLE
SEC 6 T31 N RI 9W 2.80A IN SE NE COM NE Block/Condo Bldg:
COR SEC 6, S ON E LN 1968.72'W 229.14'
TO POB S 256.24'W 455.98' NLY 245. 96' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
TH N 63 DEG E 33.27'E 450' TO POB LOT 06-31 N-1 9W
18 1/2 GRACE DEV.
Notes: Parcel History: 161
Date Doc # Vol/Page Type
02/02/2001 637934 1582/572 WD
07/31/1998 584098 WD
2005 SUMMARY Bill Fair Market Value: Assess ith:
0
Valuations: Last Changed: 07/22/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.800 44,800 271,800 316,600 NO
Totals for 2005:
General Property 2.800 44,800 271,800 316,600
Woodland 0.000 0 0
Totals for 2004:
General Property 2.800 44,800 271,800 316,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 129
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
rr
AS BUILT SANITARY SYSTEM REPORT
OWNER ~bOa~G~ -a a r arse V-, TOWNSHIP -Sa m ~r~ e~
SECTION (A _T,_N-R 9 W
ADDRESS So~ 0 T. CROIX COUNTY, WISCONSI
ll J
SUBDIVISION C kaC,e SQ4eY . jc Qfl IILOT I LOT SIZE
PLAN VIEW
SHOW EVERYTHINQ WITHIN.100 FEET OF SYSTEM
6. f.e
f
~rI ae
n
,g►
1'7`a Esc ~
INDICATE tRTH ARROW
BENCHMARK:Elevation and description: J4e /6~
Alternate benchmark
SEPTIC TANK: Manufacturer: Liquid Cap. 600 Qa)
11 ri r
Rings used: l Manhole cover elev: 19~A*inal grade elev: .
Tank inlet elev.: /,00, Y7 Tank outlet elev.: A0,6, x:z-.
No . of feet from nearest road : Front , Side, Rear Ft.
From nearest prop. line:Front , Side, Rear Ft. 32
No. of feet from: Well ~o Building: -38 /
(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 1
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: X;2_Length lc6 Number of Lines: .2 Area Built, 16 ~
Exist. Grade Elev. 9g-3 Proposed Final Grade Elev. 27_
Fill depth to top of pipe: "
No. feet from nearest prop. line:Front , Side, Rear Ft.,.%Z
No. feet from well: -SSA No. feet from building ~c
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
i
i
Lv%~TI~PartmenOtio n us rT 6.31.19•PRIV~ATE S'EW~►G OS~YSTE~VII~ LOT 10 1 113
Cou y:
La~ior ar~THuman Relations INSPECTION REPORT
,Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary ermit o.:
GENERAL INFORMATION 17-14
Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.:
JORGENSEN RONALD L & DONNA C SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9200219 oz a
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark A)
Dosi n
Aeration Bldg. Sewer
Holding - St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 3,5 /cYJ.
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic > 3 NA Dt Bottom
Dosing NA Header
Aeration NA Dist. Pipe Sa
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand'`'
Model Number GPM S:S'
I Loss Friction System TDH Ft
TDH Lift
Forcemain Length Dia. H Dist.ToWell
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION /"2 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION TypeO C~.U~, Mode Num er:
(og S
System: OR UNIT
- s
DISTRIBUTION SYSTEM
Header/Manifold 1,, Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length ~ Dia. Length _52 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 3 - f Bed/ Trench Edges ' - q, Topsoil C] Yes E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
Z2
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ~p (~G
SBD-6710 (R 05/91) Date Inspector's Signa ure Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: 1"
SANITARY PERMIT APPLICATION COUNn `
In accord with ILHR 83.05, Wis. Adm. Code
r
PERMIT #
T Fry
~ STATE SANI
-Attach complete plans (to the county copy only) for the system, on paper not less than (_/G,
8% x 11 inches in size. ❑ ClfecKif revision to previous application
E-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PRO ERTY OWNER PROPERTY LOCATION
~ar E.v.Se,v, '/aAt%S ~ T_3f ,N,R Nor) W
PROPERTY OWNER'S MAILING ADDR LOT # BLOCK # I a 5a W a N 'V
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
5f1//to 4ty_ Sso g a N 0 c.e- V3~,b
11 TY
VILLLAGE : NEAREST R AD
II. TYPE OF BUILDING: (Check one) ❑ State Owned
So'rr,e, sue"
❑ Public 501 or 2 Fam. Dwelling--# of bedrooms PARCEL TAX NUMBER(b)
III. BUILDING USE: (if building type is public, check all that apply) 0 3 /-6
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 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 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. ❑ Reconnection of 5.E] Repair of an
System System Tank Only Existing System Existing System
B) A Sanitary Permit was previously issued. Permit 14 9 as7 Date Issued 3 2Q
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
130 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.) (Galls/day/sq. ft.) (Min./inch) ~1 gpELLEVATION
17c-,;tDA 7c;Lo t f3 a~ I..3 *sv~Feet /q~ '0' Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank OOD O! rg
Lift Pump Tank/Si hon Chamber ~X~. El 1 1-1 1 1:1
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 ) MP/MPRSW No.: Business Phone Number:
a/u/;, io we-4s lR 650.3 7/S o? S1_3S
Pl umbers Address (Street, City, State, Zip Code): L
IX. COUNTY/DEPARTMENT USE ONLY
_j Disapproved Sani ry Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
[!KApproved ❑ Owner Given Initial
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 & Buildings Division, Owner, Plumber
INSTRUCTIONS a,
1. A-sanitary permit is valid for two (2) years.
2. `--Four 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 adminlstrator'or the+
State of Wisconsin, Safety 8 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,
experi,mentat 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; 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`tf~county; E) soil-test data on a 115form; and F) ail sizing information,
GFIOUNDWATER 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)
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C Fr4In Ali Inle1► And Ob►urollon Pipe
J c;L ^ Approrid V•nl Cop
Mlnlm- 12' ALo.e
~~~~Qr ry~~ flnol Grad•
20 - t2' AEo.o Plpp _ 4' Cost lion
To flnel Olliee Vonl Pipe
wren liar Or Srn,Wk Covering
lun 2' Aggropol►
Over PIPo
04Ulevllon •
o +
Pipe o 0 0 -To
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9enoolk Plpo o porlorole0 PIP$ Belo,,
o COVIInq Terminollnq Al
" 9ollom 01 Slolem
PIrle-~
SOIL FILL
'DISTRIBUTIOf.1 PIPE
'C APPROVED S41J IIETIC COVC
• _'-AkTEIZ1,\1. OR 9.• OF STRI.bJ
2"OFi\GGREGA"fE--~~ ORMARSN HAS
9 l."OFlZ-212 AGGRCGATE
ELEV. oFFEET~
DIS'T'11151JTIOM PIPE TU BE AT LEAST _ IUCHES BELOW ORIGIIJAL GRADE
AQU AT LEASTLO IIJCHEL BUT 1,10 MORC THAI) 42 II.ICNES BELOW FIrJAL GRADE
r'AXINUM DEPtH OF EXC/IVAT100 FKOM ORlt, JAL G~AVR WILL BE 11JCHES
rJNIMVM OEPTA of EXCAVATIO" r-ROM. C~161taAL GRADE WILL BE a INCI-ICS
51GI.ICO.
LIr_rUSC LJUMBEIj:
DATE:
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IVISION
I-NDUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION. TESTS (115) MADISON, WI 53707
HUMAN RELATIONS (H63.09(1) & Chapter 145.045)
LOCATION: SEC IION:- TOWNSHIP/ 661 Y: LOT NO.:BLK. NO.: SUB-DIVISION NAME:
E /r~~/ 6 ~T 31 N/R191vor) W Somerset 18%Z n/a Grace Develo ment
COUNTY: OWNER'S ME: MALING ADDRESS:
t. Croix Ronald. Jorgensen 112;24 Quail Way N., Stillwater, r'n. 55082
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: j PROFILE DESCRIPTIONS: E!- ATIQN TESTS:
~esidence 3 n/a - :UNew ❑Replace 3-10-92 yL
-
RATING: S= Site suitable for system U_=__ Site unsuitable for system
ONVENT ONAL: Ms ND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑U DU I, HS ❑U ❑ S EN ❑ S RM conventional
If Percolation Tests are NOT required ESIGN RATE: ( If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n/a. Floodplain indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
02 0-8, 10yr4/2; 8-18, 10yr5/4, s.sil.; 18-29, 7.5yr
B-6 84 96. none >84 4 s.l.• 29-84, 7.5 4/6 Co. S.
r -8, y 10r5 ' sil.• 16-30 -
10 r 2 l.• 8-16, Y
B-7 84 95.12 none >84 7 0.5yr4/4, s.l.; 30-84, 7.5yr4/6, Co. S.
98.42 0-10-, 10yr4/2, 1.; 10-22, 10yr5/4, s.sil.; 22-
0_8 96 none >84 281 r4/4 s.l.• 28-96 10 r5/6 Co. S.
B-
13-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P D 1 P RIOD 2 PERIOD PER INCH
P-1 4.30 none 3 6 6 6 <3
P-2 3.40 none 3 6 6' 6
P- 3 2.50 none 3 6 6
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 94.32
m~'~ _ _ _ ~ ~ i ~ . s z,tiI
t I L I i i ,tD
6'
~ok
i
i i
~ ~ ~ X31
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 Wisc nsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. I
NAME (print : TESTS WERE COMPLETED ON:
Gary L. Steel 6-4-92
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Id. 54017 2298 15-,t46-6200
CST SIGNAT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
' SCP*71:C AMK %IAL.1Tr•.MAHCE ACMZZ•MENT
Sr.. Croix Cuuncy
OWNER/BUYER =-0k -0 ~oILU~NScN
ROUTE130.E NUMBER 'l1ebS4 C~-t~zA.~-►O ~vEN~nc Fire "lumber
CITY /STATE ZIP 1;1:; l 1 C
P^OPERTY LOCATION: 51'C_ '-r., Section ( , T 31 1, 7 R 9 W,
Town of `7onnEU-T , St. Croix County,
.
Subdivision C~C1,n~ E mop , Lac number 10/2-
Improper use Xnd maintenance of your septic system could result in
its premature failure to handle gasces. Proper maintenance con-
sises of pumping out the septic tank ever7 three years or sooner,
if needed, by a licensed seocic tank pumper. What you put into
the system can at*ecc the Function of the septic tank as a creac-
ment stage in the waste disposal system.
St. Croix Count-7 residents may he eligible to receive a grant for
a maximum of 607. of the cost or replacement of a failing system,
which was is operation prior to July 1, L978. St. Croix Cuunc7
accepted this program in August of L980, with the requirement chac-
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to Sc. Croix Cuunc7 Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying chat (L) the on-site wastewater disposal system is.in'proper
operating condition and (Z) after inspection and pumping (if nec-
essary), the- septic tank is Less than L/3 full of sludge and scum.
Certification form will be sent aporosimacely 30 days prior to
three year expiration.
117E. the undersigned, have read the above requirements and agree
co maincaia the private sewage disposal system in accordance with
the standards sec forth; herein, as sec by the WLsconsin Depart-
ment of Nacural Resources. Certification form must be completed
and returned co the Sc. Croix County Zoning Office within 30 days
of the three year expiration dace.
SIC,7ED ~cf,.~.~~•
?ATE 3 - l8 -9a
Sc. Croix Counts 'Zoning Office
P.U. Sox Z':7
4ammond. UT 340i5
7L5-796-Z221
5 i. '.n , Oar- :ind ri:7ttr1 "n :ihuyr_ address.
APPLICATION FOR SANITARY PERHIT
STC - 100
hie application form to to be completed in full and eigned by the owner(s) of the
toperty being developed. Any inadequacies will only result in delays of the permit
ssusnce. Should this development be intended for regale by owner/contractor, ("epee
ouse"), then a second form should be retained and completed when the property is
old and submitted to this office with the appropriate deed recording.
er of Property PtaL-o
cation of )property 5e k 1AIE 1c9 Section (o , T H-R °r W
Twmship Sk:~MZM S. .
Mailing Address 3 ~ 54- C~ « N O AvE~~
Sc,
Address of Bite 7CXCX
84hiiiii6n name _ Laf~-ac.~ C v~ ~-o~ ►rh~s
Lot Number ~$`/t_
i'revioue owner of property P.MES Ca L--`-A N D
Total site of reveal _ 2 5 4
bate Parcel was created Ali I-AkA Add 1q, 194~Are all cornets and lot lines identifiable? x Yee No
is this property being developed for regale (spec house) ? Yes No
Volume 117- and Page Number 3"1am an recorded with the Register of Deeds..
INCLUDE W1111 INS APPLICATION TILE FOLLOWINGS
'A Warranty deed which includes a Document number, volume and page number, and the
SeAI of the Resister of btede. In addition, a certified survey, it available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Nap, the Certified Survey Nap shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROEM OWNER CERWICAT10N
1 11001 CVktt y .(hat MU -Sta,tementh on tjUA ohm ahe, tkUp- to zlte beAt o6 my (ouA)
hncwtedge; Uldt 1 ("JO-1 Oil' (ahe) the rn1019-A s~ 06 the phopeltty de cAibed in ,thi,a
t"Wmatdon 6o&m, by vWue o6 a wa"ditty deed AecoAded tot the 06 ice 06 .the
Cor►n.tyy RtgtA.teA o6 Veedsm Voeumen.t No. 412bb5 ; and ,that 1 IWCI pheAvowy
aun die p1toposed skte 6oh .the seloage d.iApos sysZom (oA I (wel have obtained an
fdAc►+ent, to Aun with thv. above dv, ec&ibed phopeh,ty, oh the eon.AttuctLon o6 a did
System, and the same has been duty AecoAded tot .die 46tce o6 the Cowtty Re.9ta.teA o6
veeds t dA Ooeum"a pie. Z to to S .
t
c~.dZtJ '
IICNATUM of OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
3
DATE SIGNED DATR eTnMrn
DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
•2 f~~~~ STATE BAR OF WISCONSIN FORM 2-1982
VO! 9142PAGE 377 REGISTERS OFFICE
James G. En lund and Shari L. En Lund ST. CROIX CO., WI
g---.......... Rec'd for Record
husband and wife, as joint tenants, .
at 5 A. M
conveys and warrants to -.Ronald_-L.-. Jorgensen,_-an._undiyided-__-..- 0 a-YA
r V l~
_..-two-.thirds.. (2/3)._Anterest., _.and..Donna. C.-Jorgensen.
-an..undivided..one-third._.(1/3)...inter est.,,..as.. tenants--------- . Regisiet of Deeds
..-..i_n_.common__and__not_.as..joint..tenants.,_.............
RETURN TO
.
- _ . . .
the following described real estate in ......St. Croix ....................County,
State of Wisconsin:
Tax Parcel No:
Part of SE 1/4 of NE 1/4 of Section 6-31-19, described as follows: Commencing
at the NE corner of Section 6; thence S05036'40"W along the Section line 1968.72
feet; thence S88019'05"W 229.14 feet to the Point of Beginning; thence S 256.24
feet; thence S88019'05"W 455.98 feet; thence N120W 170.36 feet; thence N08056140"E
75.60 feet; thence N63000'20"E 33.27 feet; thence N88019'05"E 450.0 feet to the
Point of Beginning.
TOGETHER WITH AND SUBJECT TO an easement across the N 33 feet of the above described
lot for driveway purposes for the mutual use and benefit of the owners of the
above described lot, their successors or assigns, and the owners, their successors
or assigns, of the lot described in a certain land contract recorded in Volume
"517", Page 634, in-.,the Office of the Register of Deeds for St. Croix County,
~_L1isc'ons1n.
1 pU
F L E
This is not homestead property.
(is) (is not)
Exception to warranties:
Subject to easements, reservations and restrictions of record.
//ll 91
Dated this ---l.W~----------- day of Auu_st - 19 ~Vl 40(-
- - ..(SEAL) _.\~-1......-._r~ (SEAL)
JAMES G. ENGLUND..........
-
(SEAL) G -I,L!YL. (SEAL)
* + SHARI L.,.,ENGLUND
-
AUTHENTICATION- ACSNOWLEIIGMENT
Signature(s) STATE OF WISCONSIN
J/! CIO S3.
County.
authenticated this day of___________________________ 19...... Personally came before me this ...&A-day of 7lugust 19...91. the above named
James G Fn lund and Sh g-
g ari-- L,_• En lund
+
TITLE:
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
authorized by § 706.06, Wis. Scats.) ne known to be the person _S. .yho executed the
n~ rUIDUGfg~egoill strunlen nd acknowledge the same.
THIS INSTRUMENT WAS DRAFTED 8.~`.~~F
STEPHEN J_ DUNLAP--------------- _ _
Hudson, Wisconsin Notary Public County, Wis.
-
(Signatures may be authenticated or acknowledged. Both My Co Mission is perm rent. (If not, state expiration t? .2
191-.
fj are not necessary.) date:
-
•Names of persons signing in any capneity should be typal or pri"Ird b0ow Ilwir sigma Uno!<.
f
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1200.72
i 890
/ 2.653 ACRES 3.313fCRES - 1
4A° / 47446 Coo/~
40 / ) 1.883 AGiE
525.24 5.005 ACRFSS "
45 ~ 8 2.772 0 Z _ 6' ~a/.-•''•..
N f/
46° / /Q4S RES f 821.
410 .036 ACRES 900
2g'
2.557 ACRE
44° $ 14` . 56.34
0
,Zoo* _ 2" 5.456 ACR
i- O
` _ 9\ Z 759 ACR~S
44,
1 `
450.00' 22914' - 1
818 44
i I S42-d
5.984 ACRES
_]G.n02.803aCRiS ~ (
A.Sd
00/ 672.39 7397 ACRES J t"/¢I~~
°j - 7.268 ACRES
a 66'WIOE ROAD S ~,I l
3.0 S
7316 ACRES f 773.32 nnd 667791f '
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m 1 { I/2 39004 ~,/jS -g
N 2.503ACR y/O 6.626 ACRES\~
125 ACRES !p 'j0 1/2 e 4
G 9 iV 90
900
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6.707 ACRES
e /1y0 %1)
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2.517 ACRES
9 100
rye,. a` l t,•
7107 ACRES
_s 910 ~$031 ACRES
890 g p 82SA0880 J
10 \ $ 660.00
17399 ACRES
870 \ - y0~ ACS
5.137 ACRES
~j 1 10.014 ACRES
860 r~ 100
35.ad 835.71 96~ O
06° 41 0 .A
40 6' p
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O
NOTE: SHADED AREA INDICATES WOODS -
/IID4t6T TITL9 GRACE DEVELOPMENT COMPANY "•11'•'•"'
ff engineering company P.O. BOX 8626 *An
I. U1111* 0 ND URVIV1N •bnMMR9 DOWN WHITE BEAR LAKE, MINNESOTA 55110 '
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LOCATION: SOMERSET 6.31.19.85J,SE,NE,6, CO. RD. I
Wiscongn Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
andBuildings Division INSPECTION REPORT ST. CROIX
•Safety
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 149287
Permit Holder's Name: ❑ City [I Village ]V Town o : State Plan ID No.:
JORGENSEN, RONALD L & DONNA SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032101695000
TANK INFORMATION ELEVATION DATA A9200133
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outl 1111100" 4111L
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt B om
Dosing NA Hea er
Aeration NA Dist. Pipe
Holding Bot. stem
PUMP/ SIPHON INFORMATION Final Gra
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System TDH Ft
mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No \nches-PIT___TNo. . Tre Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG KE / STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Mode 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 7_1 I
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH
1
SANITARY PERMIT NUMBER: '
3
L
'C~ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CO
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than / y Q a, p7
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PR PERTY OWN R PROPERTY LOCATION
rl n E~Y--. 50%111 Y4,S rv TN,R Al laor) W
PROPERTY OWNER'S MAILING APDRESS LOT # J~ 1~ BLOCK #
a W ON N I
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
r a .2 r e 1~~v-v~
15h / S
Au aftc k, I
II. TYPE OF BUILDING: (Check one) CITY ,.t_ ❑ State Owned ❑ VILLAGE NE ESTROAD
OF: -III a 11 5-e
❑ Public S 1 or 2 Fam. Dwelling-# of bedrooms(,- FARCEL Ax NUMBER(S)
ill. BUILDING USE: (If building type is public, check all that apply) 03 ON -)Z) J&
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPP jE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~I New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 420 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
7,')00 1 7, 00 9615 Feet Feet
VII. TANK CAPACITY Site
in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concret structed glass App'
Tanks Tanks
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.
Pl er's Nameq"t): Plumber's Si atu : (No mps) rP/MPRSW No.: Business one u Number:
rc e n sb Y6 ~sr3s
Plumber's Address (Street, Ci Mate, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
7❑ Disapproved itary Permit Fee (Includes Groundwater ate Issued issuing an Signature (No S m
Surcharge Fee)
Approved ❑ Owner Given Initial / 4/ao z c _
Adverse Det rmination
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
submjtted 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 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)
IIJU T;rMT-NroF REPORT ON SOIL BORINGS_AND SAFETY &BUILUIN
N
INIJUSTIVY, DIVISION
7969
[:A'ROfI !I;hU 3707
PERCOLATION TESTS (115) MADISONP.O., WI BOX 53707
HUMAN RELATIONS
(iLHR 83.09(1) & Chapter 145)
ISEC ION: TOWNSHIP/MRKkk TY: LOT NO.: BLK. NO.: SUBDIVISION NAME.
R 1/ NE 1/ 6 /T 31 N/R19:bt(or) W Somerset 18%2 n/a Grace Development
COUNTY: OWNER'S g~I~(AME: MAI NG AUDN€SS:
St. Croix Ronald Jorgensen 112524 Quail I]ay N., Stillwater, 11n. 55082
USE DATES OBSERVATIONS MADE
R
:
NO.BEDRMS.: COMMERUiTCDESCRITiTION E5 =T
-92 S S:
[~~.,iden:e 3 n/a iaNew ❑Replace 3-10-92 13-10 _A
RATING: S= Site suitable for system U= Site unsuitable for system
:UNVENi'IUN`l MOUND: IN-GROUND-PfiEW(_A ; VST€M-IN•FILL HOLDING TANK: RECOMMENDED SYSTEM:Ioptional)
conventitial
'Bs ou HS ❑u ~ ~u Ts ou a s u~~h
Percolation Tests are NOT required DESIGN RATE: it any portion of the tested area is in the
der s. ILIAR 83.0915) (b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
I,:,-
decimalt PROFILE DESCRIPTIONS page 1 OND2 IUTAL DEPTH HES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
ATER-INCHES 1 IN T GROUNDW
ELEVATION OBSERVED tZi I. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
NUMBER UEPIH= R G
N
7.Sy-/r4 /
B. 1 7.58 100.45 none >7.58 .83 7.5yr3/2 s.l. 1.757.5yr3/4s.1. 5.00 C.S.
7
2 7.00 100.50 none >7.00 1.00 .Syr3/2 2.00 lsil. 4.00 7.5yr 4/4
s.l. C.S.
B 7.5yr3/2 1.08 7.5yr3/4 5.75 7.5yr4/4
3 7.66 99.50 none >7.66 .83 s•1• s.l. C.S.
6-
97.20 7.5yr3/2 7.5yr3/4 7.5yr
B- 4 7.01 none >7.01 .92 s.l• 1.17 s.l. 4.92 C.S.
96.70 none >7.08 .33 7.5yr3 2 1.17 7s5yr3/4 6.00 7.5yr4/4
B_ 5 7.08 11
B
PERCH ATION TESTS
decimal'
TFS1 DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVE -INCHES RAPER (INCH NUTES
NUMBER O~IgH~C AFTER SWELLING INTERVAL-MIN. PERIOD 1 P.~RIOD PERIOD <3
P. 1_ 3.95 none 3 6 6 6
I,_ 2 .00 none 3 6 6 <3
-P3--. _370T_ none 3 6 <3
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.
96.50
SYSTEM ELEVATION
p r l ~ i ~ ~ I ~ I ~ ~ /K l0
10
r( I a z ( ti
Ids A~ ~.R • 1Q7 , - . ,~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 : TESTS WERE COMPLETED ON:
Gary L. Steel 3-10-92
ADDR SS: CERTIFI~ l NN BER: PHONE NUMBER (optional):
155+ 200th. Ave., New Richmond, Wi. 54017 ``JJ 1715-244-6200
CST SIGNAT "R
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester,
Ifi SI{U R't9ri Ili. 1Ui83) OVER
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Froth Alt I41a1► And OD►errallon Plp►
SSO A rov10
vp Vent Cup
. , ulnlmwn
12' Aoore
final Greg.
20. 42' Above Pip' 4' Coal Iron
To final credo Vent Pipe
►aoran 140Y Or Stnlt sk Co-tiny
Lin 2' Appropais
Over Pipe
DlarrlOvllon '
PIPo 0 0 0 Too +
fole, Pipe Perloralad Pips below
' Bonat~ Plpa o
o -'Co.plln0 TerminUlny At
agleam Of system
1,60
SOIL FILL
'pI5TKIBUT101.1 PIPE '
;r APPROVED S4gpAETlc cover
r, .r "--MATERIM- OR 9., OF STRAW
2"0f hGGREGAZE - OK MARSH HAy
4 w
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qq~~ 'i; Y O F lZ - 21/2 A G G rt c GAT E.
ELEV. OFZ-i $EET-►'
0ISTRI51JTIUrJ PIPE TU 6E AT LEAST lur-HES BELOW ORIGIIJAL GRADE
AUU AT LEAST LO IIJCHE-1 BUT MO MORE THA1J 42 IMCIMS OELOW FI►JAL GRADE
I'1AXIMUM DkPrH OF EXCAVATIDO FKOM ORIbWA. 6~ AK WILL BE MCHES
nK1t1UM (Kpni OF EXCAV,ATION r-POM 0~161W\L GRnuF- WILL. BE INCIIC5
SIGIJCO:
LIGCUSC l)UMBEIi: J
OAT E t- 119 111919-2
- - 110