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HomeMy WebLinkAbout182-1016-10-000 ~1. AS BUILT SANITARY SYSTEM REPORT OWNER f12'4/II,- SECTIONT -3 N-R / W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION I LOT-JJ LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i~ CC \ ~ ICI /-7' r r l I 141 5Jv ~ INDICATE NORTH ARROW BENCHMARK:Elevation and description: 91-w.:h lwarnE-~lQr0✓~°no,~~~'/Cr~~~C Alternate benchmark SEPTIC TANK: Manufacturer: 6~S Liquid Cap./ idlj Rings used:.aManhole cover elev: Final grade elev:_,/ 4 Tank inlet elev.: 112 85 Tank outlet elev.: 97 sz No. of feet from nearest road:Front-,K, Side , Rear Ft. From nearest prop. 1 ine : Front , Side k, Rear Ft . r No. of feet from: Well r5? V , Building: / 7 11 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE i PUMP CHAMBER Manufacturer: liquid Capacity: Pump Model: Pump/Siphgn Manufact.: Pump Size r Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front-, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: .SC~~ 'Q Width: ength ~LO Number of Lines: Zz Area Built Exist. Grade Ely;Xza Proposed Final Grade Elev. l7 j 7c 33 Fill depth to top of pipe: 2- - No. feet from nearest prop. line:Front Side, Rear Ft.-3 No. feet from well:. .d 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: C INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: r3 zS 6/90:cj r 1$ c~ ,W,T4Q Ttn rr+ VmdV4IRIE, 1.3 Labor and Human Relations IVA~~►GET 11A County: 'Safety and Buildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 186526 Permit Holder's Name: ❑ City ❑ Village ❑kown of: State Plan ID No.: MINXTy STAR PRAIRIE F W,^ Insp. BM Elev.: BM Description: Parcel Tax No.: If J-, GCS` G, '5arr2 ;,,s c"-, TANK INFORMATION ELEVATION DATA A9200410 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic _ Benchmark 77' 60, C© D g Aeration Bldg. Sewer Holding St/)rK Inlet OZ~ TANK SETBACK INFORMATION St/)0 Outlet 3Z gym' TANK TO P/ L WELL BLDG. Ventto ROAD Dt I t - Airlntake Septic 17Gp ` Z NA Dt B - - NA Header / P4er 9z' S az 9s~ 93• s' Aeration A Dist. Pipe 9 145 W Holding Bot. System , PUMP/ SIPHON INFORMATION Final Grade Manufa Demand Mo el Number GPM TDH Lift Friction S stem Ft Loss Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Sb D MEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK , A odel Numbe INFORMATION Type O y7t CHAMBER 5! f}- OR UNIT System: -7// DISTRIBUTION SYSTEM Header / MOM ilielm „ Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia. Length 4 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over „ p xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 27 -3 Bed /Trench Edges ;Z7-z4 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE, 1.31.18,NE,NW, 5TH ST. Plan revision required? ❑ Yes Use other side for additional information. /q FWF/QZ. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I R SANITARY PERMIT APPLICATION ~DILH In accord with ILHR 83.05, Wis. Adm. Code COUNTY ©ILH St. Croix STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than L®(,)Q~'D in size. ❑ Cfii~k iNewsi~ Previous application x 11 inches 8 /z -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 ninnie Larson '/4, S 1 T 31 , N, R 18 )&(or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 540 5th. St. n/a n/a CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Star Prarie, Wi. 54026 715 248-3472 n/a . TYPE OF BUILDING: (Check one) VITM NEAREST ROAD VILLAGE : Star Prarie 5ht. St. 11 ll~~ll ❑ State Owned # TOWN OF: ❑ Public Lit or 2 Fam. Dwelling- # of bedrooms ? PARCEL A ER ) Age- 16-1 ~Q III. BUILDING USE: (If building type is public, check all that apply) 1-31 I J/ 1 2_ A; 1 ❑ Apt/Condo (J 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 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. ❑ New 2. Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.E] Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Ri Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 140 System-In-Fill Vl. 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) 93.80 ELEVATION 300 500 500 .60 .6 91.20 Feet Feet VII. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank x 1000 1 1Jeels C. P. Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst lation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb S' ature7(Non1D81 MPRSW No.: Business Phone Number: Gary L. Steel r3254 715 246-6200 Plumber's Address (Street, City, State, Zip od IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issu nt Signat o m Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASON FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/(38) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owffbr'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 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 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) STC -loo This application form is to be completed in full and signed b the owiicr (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 !louse), 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 Minnie Larson Location of property NE 1/4 NW 21 18 village of 1/4 section _ ' 1 T N-R W Mo"xb&p Star Prarie Mailing address 540 5ht. St., Star Prarie, WI.54016 Address of site 539 5th. St. Star Prarie, WI. Subdivision name n/a Lot no. n/a Other homes on property? x ___.yes_ No Previous owner of property s ~s Total size of parcel 86.9 acres Date parcel was created 2 Are all corners and lot lines identifiable? ___.x yes No Is this property being developed for (spec house)?_Yes L -No Volume Zgnd Page Number / Z of Deeds. as recorded, with the Register 114CLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIWITY DLED which includes a DOCUMENT NUMER, VOLUHE AND PAGE. NUMBEIR & T11B SEAL or, TIME IZEGISTLIt 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 certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the property described in this information form the owner(s) of by virtue of a warranty deed recorded in the office of the count Re Deed; as Document Ho._5=1 Y gister of own the - , and that I (we) presently ~ proposed, site for the ewage 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 the office of county Register of deeds as Document No. Sign ure of ap~l cant Co-app! cant i Date o g i na re Date 51 signature { ~ P ~A rt ii r, i z~A i s xY~ r .~r ~ r -r ~ k;*; rk' `q F Y n ? ~ aa~ ~ ~S 1. SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/B, Alinnie TarSC)n ADDRESS: 540 5th. ST., Star Prarie, Wi. 54026 FIRE NO: LOCATION: -NE-4 1/4, SEC. 1 T 31 N_R 18 W village xIW9N OF: Star Prarie ST. • CROIX COUNTY SUBDIVISION: n/a LOT NO. na/ 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. SIGNE • I. DATE: St. Croix County Zoning office 911 4th St. - Hudson, WI 54016 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of-Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St . Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION ?linnie Larson GOVT. LOT NTE 1/4 Mq 1/4,S 1 T 31 N,R 1$ )(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 540 5th. St. n/a n/a n/a CITY, STATE ZIP CODE PHONE NUMBER ❑CITY tBXLLAGE ❑fOWN NEAREST ROAD Stnr Prarip, WT_ 54026 (715)248-3472 Star Prarie 5th. St. [ ] New Construction Use [x)c Residential / Number of bedrooms 2 [ ] Addition to existing building ]i Replacement [ ] Public or commercial describe Code derived daily flow 300 gpd Recommended design loading rate • 5 bed, gpd/ft2.6 trench, gpd/ft2 Absorption area required 600 bed, ft2 500 trench, ft2 Maximum design loading rate . 5 bed, gpd/ft2.6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 93.80 & 91.20 trench ft (as referred to site plan benchmark) Additional design / site considerations trenches to be 3.50' below surface level. Parent material o-Ltwash Flood plain elevation, if applicable n/a ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0 S ❑ U fR S ❑ U f S ❑ U faS ❑ U ❑ S M ❑ S EU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxldary Roots GPDin. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed r1 0-10 1 r3/3 none sl. 1/f/ r. mvfr c/s 2/f .5 2, 10-86 10yr4/6 noen 19. 0/sg ml n/a 1/f .7 Ground elev. 97.30ft. Depth to limiting fact Remarks: Boring # 1 0-11 10yr3/3 none sl. 1/f/gr mvfr c/s 2/f .5 .6 2 2 11-24 10yr4/4 none sil. mfr 1/f/sbk g/w 1/f .2 .3 3 24-40 10yr4/6 none S. ml 0/sg g/w n/a .7 .8 Ground elv. 4 40-84 10yr4/4 none ls. 2/m/sbk mvfr n/a n/a .5 .6 94.7Q. Depth to limiting factor >84 Remarks: CST Name:-Please Print Ph ne ary L. e 1 715-249-6200 Add M4 20 Ave., new ichmond, WI. 54017 Signature: Date: C T IIyyu ber: 11-16-92 2yf PROPERTY OWNER Minnie Larson SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounfty Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench '1 0-9 1 r3/3 none sl. 1/f/gr mvfr c /s 2/f 6 2 9-27 10yr4/4 none sil. 1/f/sbk °/w 1/f .2 .3 Ground 3 27-86 10yr5/4 none ls. 2/m/sbk mvfr n/a n/a .5 .6 9y1e~-0 ft. Depth to limiting factor *97.30 Remarks: Boring # Ground elev. ft. Depth to limiting factor L Remarks: Boring # _4X Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Minnie Larson 988 N. Shore Drive C.S.T. 2298 NE%N[d% S1-T31N-R18W New Richmond, WI 54017 MPRSW-3254 Village of Star Prarie (715) 246-6200 '73r V a I YYI L ~y►1 ~yr~~✓~~ I!, STEEL'S SOIL SERVICE Gary L. Steel 988 N. Shore Drive C.S.T. 2298 Minnie Larson New Richmond, WI 54017 MPRSW-3254 NE NW'', Sl-tKN-81814 (715) 246-6200 Village of Star Prarie .0 -y- too' A,3 i 1 I,r rl c o _ e-N REPT131 STAR PRAIRIE ST. CROIX COUNTY ZONING PAGE 1 11/17/92 11:38 REQUESTS FOR INSPECTION WORK SHEETS FOR: 11/19/92 AREA: JT 'Activity: A9200410 11/19/92 Type: CONVSEPT Status: PENDING Constr: Address: STAR PRAIRIE, 1.31.18,NE,NW, 5TH ST. Parcel: - - - Occ: Use: Description: 186526 Applicant: LARSON, MINNIE Phone: Owner: LARSON, MINNIE Phone: Contractor: GARY STEEL Phone: 246-6200 Inspection Request Information..... Requestor: STEEL, GARY Phone: Req Time: 15:11 Comments: 31,36 Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION c O O c.; ao i o i o I a O o e r. o o m h O ti U N I I a c co ~ I N L y N N O i) M O X Y C C Z c C 3 m w C LL O q - 0 C U Q a of E Q I V N O N CL 3 z w z l c p o o z d m `m 4) Z II a m a m c I o i c U v O z c c a~Ui Z o c O 1 O N F- c a E z N N M 'a 0) a) L Q N N N 2 U) C 01 O N N • _ L I CL d L O C O U V 0 z m z z z O z U c -o d "O N N C E O O 1 J 4) CL M m 05 CL }\i N y d_ N i~ N O O co G a N O G G 04 04 U) U) N~ E a ~ ~ N _ 0 0 0 O Z o ~i E O O •ti m a a a a a a y a c 7 O y 0 co N .m N N N tl1 J V ! EL 0)~ Q) d 0) W N LO (0 C14 04 0 0 ~ ~ ~ E I co m s v 'a°-' ¢ i Lo Q z u N y uo N ~0 O O 3 7 N y O N C O W C C N E to ce Z N ~ d m > co 2 a) m N E 0(n M -6 '6 w 0 w C L O CO cc) -0 .ems- N Z O O Z~ O N m m o co E i co E L LO 0 • co O J M Z N 2 I- (a O N H U) O ~ r xt v V] a; a L y a ~a d • cl a w .0 d d c m y c `F~c c c r ~1 A v a t ! O H o O h v I • AS BUILT SANITARY SWTEM REPORT :vER.,P&n r%/ LQ 1, _s6n , TOtdNSHIP SEC. T21_N, RAW 0. ADDRE S.. d , ST. CROIX COUNTY, WISCONSIN. + 1 1, '3DIVISION LOT LOT SIZE tZ /f PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM pry F- s TIC TANK(S-.0 MFGR.tIa~~s ~ye. Gas T CONCRETE STEEL 0f rings on cover Depth DRY WELL .INCHES NO. of width length area 3 no. of lines 3 width /S' length 3 S , area 4~ is depth to top of pipe 3REGATE q UK RATE C7 _ AREA REQUIRED ` / S AREA AS BUILT 4` S ;claimer: The inspection of this system by St. Croix County does not imply complete pliance 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 Item operation. However, if failure is noted the County will make eatery effort o ermine cause of failure. -'ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. c "INSPECTOF~-'DATED PLUMBER' JOB LICEN: NUMBER 'r . so- ~ ~ ~ u / C 3'h o~ ~ l<~.~,on C ~IIM6Y Lcsiar a - e h 0 a \ \ y \ 1Jo~~z/d /lath. P ~Q d e~ ( CEDAR ~y d j~~x d zoz h /~J1 / ~a HH vC3v ~E Ua~ .Pss F ~ ~C a 0~ ~:9!u,; 'C"1 st /ibcan /.3z O v i/~ 0 h Q\ a. /O U 0 n "'fi't ✓P.- e.~6 ~Pf.9 ® LUec~ p ~'0 h j 3•C m 4~ /~.L7 / 6 ~~e% f ah_ /1o ts'~✓!2 d /60 a p C h ~~,3~~ ,x.30_ ,Q ae / ~.h~ C a ~D .W a• . o~ bee: C "S .0 0 M e \a oseff4 tl d\ s -41 s 9° 36 /~7U/lei/ ~1 d C v n 0 Y T 0111 • ~f SEA v~• x v .za osE. v° n¢~ HUNTING cy tl 4o e e o ° c h ~ 40 ~ o a ,Pr uec~ ~S~//✓¢~ H r ss.. ~f,5c v\ W Y~ t Cc~a d e nan s ~0 ~ /4 4n E/ ems' ~ 44. „9 W Ql BO C w Ch fte L a~so~ /Ve/son I,~ C Q tl~ ~~ncz~ Ca°.4 ore 170 Rob H M'R( ti S'i ibo > W ti Z c® 1z /I/e/sow •/GO P C ix• qM 39 'b C C/ff< Co a ~e go . y nd ea / - ~ \\w\ Q 40 cgs a man ~ S:.Gt.3. 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C ax C unty 64 Wls v/<< It PLAT BOOK COMMITTEE A~o SI-P66 EXECUTIVE COMMITTEE io Mr. David Afdahl Mr. Ray Mitchell, Jr. Mr. Robert Draxler Mrs. Eldred Moe Mrs. Arthur Feyereisen Mrs. Robert Pitschneider Mr. Richard Heebink Mr. Talley Roquette Mr. Richard Kruschke Mrs. Harlan Tiberg Mr. Eugene McPhetres Mrs. Robert Zwald Cont'd on page 59 , REPORT OF IMSPECTIM--I14DIVIDUAL SEWAGE DISPOSAL SYSTEM sanitary Pernit/ ra State Septic •'.A:IE T&JIJSHIP< • t. Croix, County SRDTIC TA7111 /Vte f I Size ~ gallons. `umber of COMDartments { Distance From: Well ft. 12% or greater slope ft. Building' ft. Wetlands f~ Righwater ft, DISPOSAL SYSTE1 Tile Field or Seepage Pit(s) Distance From: yell ft. 12%.or greater slope ft Building w2 S ft. Wetlands FIELD Highwater ft. Total length of lines Oft. Humber of lines 3 Length of each line ft. Distance between lines ft. Width of the trench ft. Total absorption area - ._sq. ft. Depth _(4 of rock below tilein. Depth of rock over tile 2- in.. Cover Dver.rock., Depth of tile below grade Z-a-in. Slope of trench in ner 101 ft. Depth to Bedrock ft. Depth to ground water £t. PITS Number of pits Outs* le er ft. Depth below inlet ft. Gravel around es no. Total absorption area sq. ft. Square feet of seepage trench bottom area required. :square feet of se age it are quired Inspected by: L Title:.. Approved Date ~197e Rejected Date 197 , y EH 1,15 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORIN ND PERCOLATION TESTS LOCATION: /4,AIZAA, Section _dl N, R&-E-(or ownship }x►4+t~/~T2 ,G 12 C Lot No. ;74zp_ k o. County C! 12-0 ix Owner's Name V )_4 12 SG'u,/ ion Name : np nn Mailing Address: kk S'-1-Is /L PQ/-~ ~ R 1'4~ TYPE OF OCCUPANCY: Residence 9- No. of Bedrooms ! Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 8 PERCOLATION TESTS SHEET IS 77 SOIL TYPE' 74 SOIL MAP 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 MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- 1 ~l(v S~ ~an C ~oL C~ f i✓c~~ut /a 3/ ; P-zs~-, P-3 ~q V0 I 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) 97 q /!/.0A1- 7 0 eC -32LS _ _ 3 -7 'A u~c y a o .-r a~ q_ /a d- At/a 7 - -2 Gs J - 7 til 7.2 wy 2- 0--r6CIS' -Z. PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square'fg et of suit ble a s. Indicate number of square feet of absorption area needed for building type and occupancy. yid Indicate scale or distances. Give horizontal and vertical reference poi s. ndicate slope. /o d G Oil A a a a ° I► q 5' a • N 71 000, 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 location of test holes are correct to the best of m nowledge and belief. Name (print) tic 6~Lr/ c~v Certification No. S Z Z ~Z Address / BOX jg-7/ t-d- Ckj 1 Name of installer if known COPY A LOCAL AUTHORITY CST Signatu ti - , ry J - f, } i ~ ~ ,t1a _ w , ~ _ . _ _ _ ti_ _ _ _ . __L . 1 _ 1.. _ ~ C - , .~__4...-~ ~ ~ - .l , j , i , _ ~ ~ ~ ~ ~ . ~ ; s f 1 ^ ~ ~ 3 _ ~ s R ~ v . ' «Z k~ • s t , - ~ f i' i a i i ~ -i State Permit PLB67 State and County _ Permit Application County PerrTV Count - for Private Domestic Sewage Systems Y 1 _44 f_ *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: f4 , ~ t- Z- a k S o A R ,Q ZV'i S Ta k P r B. LOCATION: A!,W, Y4 , Section Tj_L N, R (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township S74, t, C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family _4 Duplex No. of Bedrooms o` No. of Persons-_ D. TYPE OF APPLIANCES: Dishwasher _X" YES NO Food Waste Grinder YES__~(_NO # of Bathrooms Automatic Washer _X_YES NO Other (specify) E. SEPTIC TANK CAPACITY 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) _;C_ 2)_9_ 3) -Total Absorb Area sq. ft. New < Addition Replacement *Fill System Seepage Trench: ! Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: LZI)w Width Depth " Tile Depth 3 Y " No. of Lines 3 Seepage Pit: Inside diameter Liquid Depth Tile Size 9r Percent slope of land Distance from critical slope 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 ~Qa ~h c ✓ ~e h I' C K So ti C.S.T. # s~ ' a Y.T. and other information obtained from & (owAa4;/builder). Plumber's Signature e ; ev MP/M~pftsw# Set S?- Phone #o1 ?Y- 3 7 Y3 Plumber's Address 4'..j PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). E + _ fa e { E Do Not Write in Space Below FOR DEPARTMENT USE ONLY OU 7 Date of Application / ~FesPaid: Steat A IC, C Nameount ` _ Date 4 Permit Issued/ l34}eeEed (date) Issuing Agent Inspection Yes No Valid# Date Rec'd 1. county (whi *ecopy) 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