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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT St. Croix
Salty a~ui;dings Division
+W (ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION SE4,NE4,Sec. 9,T29-Rl6,240th St. 149209
Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.:
591-40640
CST BM Elev.: Insp. B E ev.: BM Description: Parcel Tax No.:
10
e £TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 66 Benchmark IODo~
Dosing ` I
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
irl
Septic a J,D NA Dt Bottom 01 Dosing .t 6,t, , NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number /,)APM
TDH Lift Friction System TDHI(.Il Ft
Forcemain Length 45 Dia.:' Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH WidthZ 61 Length No. Of Trenches DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
'
DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION TypeO CHAMBER Moe 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. k__ Spacing I~`I `~1✓
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 I- ❑-Yes E] No J2* Yes E] No
as
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 1 4/~ 1 ck
SBD-6710(R 05/91) Date Inspector's Signature Cert. No-
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
E
/Au
c
I
SANITARY PERMIT APPLICATION
LL HR COON
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITAR ERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1
8% X 11 inches In size. Check if revisb to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PROPERTY LOCATION /
L(t Qjo t/a , E %,S Toaf,N,R /b E(o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
V4 M 'St r- I
C TY, T TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
11. TYPE OF BUILDING: (Check one) CITY !1 NEAREST O~ /
Ell State Owned ❑ VILLAGE : RF.J['~~y`
OF:
NUMBER(S)
❑ Public or 2 Fam. Dwelling-# of bedrooms ARE AX
III. BUILDING USE: (If building type is public, check all that apply) to ~e -
1 ❑ Apt/Condo cc fff
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
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. ~R Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0. Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 N Mound 30 El Specify Type 41 El 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.) (G7' /day/sq. ft.) (Min./inch) ELEVATION FZ7 c5 Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank L at 060 V lt4'Its
Lift Pump Tank/Si hon Chamber "15 0 !f
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb 's Name (Print): Plum ignature: (No Stam ) MP/ N Business Phone Number:
TJ6AJA 5' X Jjj&A.,f
Plumbe,LgAddr (Street, City State, Z ode): q n
&.11/ &LI
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater a to Issued Issuing Agent Signatur o Stamps)
,may{ Surcharge Fee)
ly J Approved ❑ Owner Given initial _
~ Adve D termination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
Document No.', This space reserved for recording data
HOLDING TANK AGREEMENT
Agreement Date
This agreement is made between the
- - - - - - - - - - - - - - - -
County or Local Governmental Unit I Holding Tank(s) Owner(s)
I 6-Ute- 0- Penn y/ ,OanleS077
Called Municipality below
We acknowledge that application is being made for the installation of (a) holding
tank(s) on the following property, (Provide legal land description:)
N 833 /3~,, Return To
_ YAy.. Aft %A /272. G7 ~ ;TAV16 .
bn ..~hi _ of ._~G c _ J '
!J iu~ cd ne 12.77-97-Ft Iv
W 4~ 3 -1J77,emit s li
~Ct51syi 5 g Iq N ! 7 ;o - - I N, 3152 ,1 e~-t Tatd 5 ! inA -
brSt~aQcon'tfnued`Gs~o! t e existin &m~ises~quires that a holding-tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats.
As an inducement to the County of t tol 1L to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in as. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
C
Onner(s) Name(s5ta/'i;~45on Her(s) S a e(s) ,J/^GLC Subscribed p~ on this date:
7Y W~l
Municipal Official Name (Print) I Municipal Official Signature / 0 tary Public
My comm iopl pi es. Municipal Official Title (Print)
i
SBD-8123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
SEPTIC TANK MAINTENANCE AGREEt1ENT
St. Croix County p
) r?
Ol~1NER/IIUYER &IA;blf-~ ,/C~t n i / S~' 0
,s-i/'-i?2 Fire dumber 110:54
d
ROUTE/BOX NUMBER/1454 j2*9
CITY/STATE ~c w //1 ZIP
Gc Section~►• TjN , R & W.
PROPERTY LOCATION:' . kk7 k,
Town of St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
Prover maintenance con-
its premature failure to handle wastes.
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen's'ed 's'ept'ic tank um er. What you p
the system can affect the ' .unct on o. the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents'-may be eligible to recieve a grant ffor
a maximum of 604 of the cost.of replacement of a failing system,
whic was in operation prior to•July 1, 1978. St. Croix County
properly that
to keep their eystemrequirement
accepted this program
temsAugust
owners of all new' agree
maintained.
The property owner agrees to.submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
veri-
journeyman plumber, restricted plumber or..a licensed pump
fying that (1) the on=site wastewater disposal system is iifproper
operating condition and .(2).after inspection and pumping
apthan 1/3 proximatelyfull
essary), 't-he septic'.tankes sent less
30fdaysdpriordtoc~•
be
Certification form will
three year expiration. ~j
0
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 bythe Wisconsin Depart- v
meat of Natural Resources. Certification be completed
and returned to the St. Croix County'Zoning Office within 30 days
of the three year expiration.date.
SIGN
DATE 2l ~.,C
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
F been+nfi1w property.
La~fieee to wateasdiss; , ;
l
llrltid dais:--.. der of tembeac
(SEAL)
(SEAL) dbl..-.
sru,T>!orssn Beverly Rich r
(SEAL)
x:Ii~IATIOx ;y LaD0asan1}'
spy ..~jrglf}1e UeckerA,........ STATE OF WISCONSIN
fhl #In TbOCMM, Elton Thorsen,
' es~relt~--N itf*4e r andeq
~.dq o[.UpkeIilbez.... 19.19 Personally came before ab* this _
. it Hen Rimme
AT-
'fit, K=M= WATS>MR OF WISCONSIN
-
;mss
(Itsa~,
afd=-. bf voue. wi.. stab.) - _ ~ .
to me known to be the person
foretoint instrument and ack
TMIS INSMUMtNT WAS CMAfTM BY
L ~A..Ir1 i i...5.44Q2
Notary Public .
=a be autbeultested or err mmjodted. Both My Commission is permarrnt.
date:
".*Am* of void" swaim ta s" emmAs doom be at Pria" WOW *how 4*M%UM*.
41- 4Z-,
• APPLICATION FOR BA11ITAAT PERMIT
8TC-100
This appllcatlon form Is to be complnted In lull and signed by the ovnet(s) of
the property being developed. Any Inadequaclea will only result In delays of
the p:rmIt Issuancg, -Should thin development be Intended for resale by
ovnet/contractot,(.pac houoe), thou a second form should be retained and
completed vhan Lila property Is sold and submitted to this office vlth the
■pptoptlate deed reeotdinq.
Ownir .of property braze I I"eol-, tj ~t/CZ /%e. ISo/)
Location o f ,property 1/4 4
, Bectlon T, •R~Y
7 o wn s h i p ~--~G~~CJI ~
Mailing address 0?40 .RQ
alow /n W-1-
Address of site C CLl'rL2 S
subdlvlslon news •
Lot number
Previous owner of property L~d Gnl n, Warlerl Thotsm
Total size of parcel
Date parcel vas treated
Ara all cornets and lot linos ldsntlflablo? wr__Yss „xo
Is this property being developed Lot resale (spec house)1,__Yss -2~14 0
Volume and Page Humber as recorded with the Ragistee of Deeds.
. ---------------•---------------------••---w-----•------------------------------
INCLUDE WITH N APPLICATION V I
A aAARANTT DVID vhichInncludes a DocuHjHT HVHnIR, VOLIJNtA}rDPAOt KV1t1tR, and
the DR-kL Or Tilt MISTER OF DUDS. In addition, a certified aucvey, it
available, would be helpful so as to avoid delays of the taviavlnq proems.. It
the deed description references to a CattIlled Survey Hap, the Certified Survey
Hap shall also be required,
PROPERTY OinItR CBRTIFICATIOH
live) evttlty that all statements on this form are true to the best of ■y (our)
knovltdgef that I (we) am (ace) the owner(s) of the property desctlbed In
this lnfotmatlon totm, by virtue of a warranty deed recorded In the office of
the county Reglstet of Deeds as Dot:Ument Hoo presently own the proposed site for the newage disposal's atexi and that I have
obtained an easement, to run with Lila above descelbmd property,(wI r hthe
conattuction of eel am, and the same has baen duly recorded In the office
of t ynty R star o be "s, a ~ameh o.
1.
gnatute of Ovnar
8lgnatut oL Co-Ovnec (IL Applicable)
Date of signature Date of signature
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
~ IND~ISJRY, DIVISION
LABOR ANti . PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
3.09(1)& Chapter 145.045)
LOCATION: SECTION: WN IP U CIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME:
E MIN/R/4 E (or
C .LINTY: WNER'BUYER'S NAME: JMAILING ADD,JypSS:
. Y
USE DATES OBSERVATIONS MADE
Residence NO. BEDRMS.: COMMERCIAL DESCRIP ON: New Replace PROFILE DE ~T~ NS: TION ESTS:
❑ 913 IPER
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: S STEM-IN-FILLHOLDING TANK: REC MMENDE SYSTEM: (optional)
❑S~u 112S❑u oS~u OS u ❑S®u I&
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: Floodplain, indicate Floodplain elevatio
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHE T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
tc>j C> b (S ~ , i4 .2-5 6
B- t K P W $A u at If' 0'. 1 . n
B- of 4j / 3e) / sQ S L Z. Z`~' S lr o 5fl~ ,B~ S
B- l 0 *1 /5 a . L 3d
B- 9il
B- S~ ✓ H
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PER D2 P 03 PER INCH
~ l
P- 0 30
P_a o 310
P- s
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 9 4~0
J3. t~ A
I
r- i I
~~'~'t] ~t~ 1f ~le I I I 1 E j I
f
i t i k I
' t
~ E
3
_ E
1 1
k-
I
3 b BI
01
t
c
ed~
t
5 f!
i
3
p 7 , (
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 ( 4 TESTS WERE C7WM:
mm& S A " X, ~ ADDR ,V a CERTIFICATION U ER: PHONE NUMBER opti nal):
CST SIG A RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
J
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER L)~L40C -/~C! <LL TOWNSHIP(
SECTION C TT / N-R ~L! W
f ST. CROIX COUNTY, WISCONSIN
ADDRESS L)(2 L
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Ii
I
r
~I I
Q
i
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: l Z,
Alternate benchmark
SEPTIC TANK. Manuf acturer : Liquid Cap.
Rings used: Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front/ , Side , Rear Ft.~
From nearest prop. line:Front.,~, Side , Rear Ft. -7).~C'C'
No. of feet from: Well C , Building:
(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:/. C, LPump/Siphon Manufact. : Pump Size A3
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:
Width:. Length Number of Lines: Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
Rio. feet from nearest prop. line:Front k Side /
Rear Ft,~~°'D
No. feet from well:-)a. 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 : vtR i
LICENSE NUMBER:
6/90:cj
i
~l
t
40, 4
r ~ruC ~ b2n ~ ~l soY! 'GJ
S N See-? Td? k)
~Ojjwi
sONAGt
¢i}o,s
i
b = ,Dore NO /0lIzz
Are Prce -
1 ~
6M. 140.0 Gr~ Scorner ~fauS~°
;t
f rese~~ 5ep~~e- fOb e rbKOU4 /CJjf 29'x 7 Mauhd
J,ooogQ~ n.~~We F PreCas`~ a~ a
f S e ~s'o 9a I paw► p Tan k
Qu
.ate
F 6 q a ail
~asT. g3
gR ao 5' 17 `
' ~ vv 0 7~e Arlea 8~, Be~ow
10O.L) 'found must kfk,%;h UhAfk4
Pros ~~-C Q r; u e
o°
P.
Page _
Straw, Marsh Nay, 0r ' 1. 0 : G
Synthetic Covering
M6dlum Sand Distribution Pipe
j,- AGE SY5 J , a x-F
S~W F,
E
Slope- b
Bed Of 2
2 (Force Main
Plowed
Aggregate from
~2 r P,rr }k„ Pump Layer
sv+ O1a °0f V
Cross Section Of A Mound' System Using E -12
~
-
A Bed For The Absorption Area F _ ,-75
G /,0
Signed: A _ 8 Ft. H J-1
q -7 Ft.
License Nu&ber: 307 --4-- I I
Ft.
Date: J Ft.
Ft.
K
::z'1;4~=~e Position
.
q.~. ' . L7 Ft.
of
Force Main W Ft. '
J Observation Pipe
f]i5:ribution •
f3 ad Of 2"- z 2
Pipe '
Aggregate
Obsarvation Pipe Permanent Markers
I
Plan View Of Mound Using A Bed For The Absorption Area /
f
i
Puye Of
Perforated Pipe Detail
0
End View
Perforoted
End Cop PVC Pipe
Hotee Locoted On Bottom,
S Are Equally Spaced
A
P
PVC Force ldoin
w
i
Q
11;r HM-V-- KEXT 'ia TN- Mai WOAD
DifiribuCon
pip*
Lctl Hote Shovid Be
Nail To End Cop
D4Irlbution Pipe Layout P / S Ft.
R
S 3'
X ?0" Inches i
Y
Inches
Signed: Hole Diameter Inch
La oral Inch(es)
License 'lumber:
-3 9- . Manifold Inches
Date:
Force Main Inches
~.1
# of holes/pipe1~_ i
Invert Elevation of Lateralso~rl~ rt.
'til rv a ~ .a 3 ~ _
Ar w. of
DEFAWW, r
Lei yr^ r , J
k
• L.. 1.
PAGE OF
PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS
4"C E VENT CAP ;).)J-4064
.I. V NT PIPE
7 WEATHER PROOF APPROVED LOCKING
25' FROM DOOR, JUNCTION BOX MAWHOLE COVER
WINDOW OR FRESH IL"MIU.
AIR INTAKE I
GRADE I
I y" MIIJ.
I IB"MIIJ
COQDUIT _
IB"MIN. - - - - - - -
CNS
INLET MASIT PRO
SEAL
APPROVED JOINT ~di r1 aY I I I I
x
x I I I APPROVED JOINTS
W/C.I. PIPE W/C.I. PIPE
EXTENDING 3 y E: ( I EXTEUDIUG 3
OWTO SOLID SOIL ALARM ONTO SOLID SOIL
tr':>>L~. F 1
~s G G~pAPtNILCa ; JtG I I ON
ELEV. F T. L, v~•I I
PUMP -1 OFF
D
L L-T, CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPEC.IFICATIOUS
DOSE ^
TAWKS MANUFACTURER: (~iAb2o~~ Cr~c1-1 ~ WMBEROF DOSES: PER DAU
TANK SIZE: -75o GALLOIJS DOSE VOLUME
ALARM MANUFACTURER: 7,111k PO1 rt INCLUDING BACKFLi~OW: - GALLONS
MODEL IJUMBER: CAPACITIES: A= IWCHES OR _ GALLOWS
SWITCH TYPE: II erc or, B=-~~IWCHES OR GALLOWS
PUMP MANUFACTURER: G-0,A d1 C=- 2' INCHES OR Ale) uALLOLIS
MODEL NUMBER: l.3 f.O2, L- D=_.LI INCHES OR 0 GALLONS
SWITCH TYPE: fn f r C NOTE: PUMP AWD ALARM ARE TO BE
MINIMUM DISCHARGE RATE37-11 6pM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. Qq'! FEET
♦ MINIMUM NETWORK SUPPLY PRESSURE " . . . • I,' yy 9~
) 2.5 FEET
♦ -6-51- FEET OF FORCE MAIN X s .l. 00 FtFRICTIOW FACTOR. FEET
TOTAL DYNAMIC. HEAD = II.12 FEET
INTERNAL D SION$ OF TANK:
LENGTH ---.-_,;WIDTH L. .~*LIQU10 DEPTH y. 3.__
91GNED: A, 6u~p LICENSE DUMBER: v `
OAT Et .
ST. CROIX COUNTY
a WISCONSIN
c~
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
- - - - (715) 386-4680
June 4, 1991
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation of the Bruce Danielson property,
located in the SE 1/4 of the NE 1/4 of Section 9, T29N-R16W,
Town Baldwin, St. Croix County, revealed suitable soils at a
depth of 24".
This site should be suitable for a mound.
Should you have any questions, please feel free to contact this
office.
Sincerel ,
James K. Tho son
Assistant oning Administrator
cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM FrmitNo.:
Labor and Human Relations INSPECTION REPORT
`Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village ~Q ovyn~oof: State Plan ID No.:
CST BM Elev.: Insp. Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
S Benchmark
Septic
n 4r, cl 6,d ad *j
Dosing
AeUddU -r Bldg. Sewer
St/ Ht Inlet
Holding
l -1
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
VAO
Septic g/ 4,4 NA Dt Bottom
Dosing c°~Yl NA Header / Man.
pswtioa NA Dist. Pipe
Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM fg_
TDH Lift Friction System TDH Ft
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 DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Typeo 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.))
l G~ ' ~✓I~a~L'~C.C>7 i~! ~--C Clti.~ ~ ~ ~ ~~Cc~C°~ ~o-c-C 0~12FQ-,' ~~!e~`L~`~
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ITT
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
=7091LIHRR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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.
PROP TY OWNER 0% ` PROPERTY LOCATION
IFVIL).Z L° ri 1 - ` SO a jE7 '/4%4, S T , N, R E (or)(&
PROPERTY OWNER'S M LING ADDRESS LOT # BLOCK #
C TY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
L~ 1
II. TYPE OF BUILDING: (Check one CITY 4 NEARF,ST ROAD
❑ State Owned -7 E] VILLAGE : p/1 S
❑ Public ❑ 1 or 2 Fam. Dwelling of bedrooms ? AR Nu BER )
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. ~ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Q Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Welab, Fiber- Exper.
INFORMATION I New istin Gallons Tanks Manufacturer's Name Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank tl C ` S
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.
Plum er's Name (Print): Plu er' ignature: (No Stamps) M Business one Number:
~AJ1 ~ ~ Q _L]
333 Plumber' Address (Street, City, Stat Zip Code)' `
0 B ft S Y
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue issuing A m Signat No Sta
Approved El Owner Given Initial Su arge Fee)
Adverse Determination JQ/ lA
X. CONDITIONS OF APPROV / SO S FOR DISAPPROVA4t
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
F'
INSTRUCTIONS
A
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.
i
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 arid/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 muss: sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than E1'f 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)
SANITARY PERMIT APPLICATION
7DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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.
PROP TY OWNER - PROPERTY LOCATION
r-
f
1 t • ` r~ i /a, S T , N, R ~TE (or
PROPERTY OWNER'S M/ ILING ADDRESS LOT # BLOCK #
CITY,,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
F/A /4 _7
II. TYPE OF BUILDING: Check one CITY r NEAREST ROAD r
( ) ❑ State Owned ❑ VILLAGE . • i,.; ~ y r i 'i Y 3 1 J
19, I= f
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX Nu RO
III. 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 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) 111 New 2. V] Replacement 3. ❑ Replacement of 4.E1 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 42 ❑ 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
/ ~ U Feet Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber l
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plurubber`~')f) Signature: (No Stamps) MPAfieHS1Al.No': Business Phone Number:
J ~
Plumber's Address (Street, City, State, Zip Code): f ft
IX. COUNTY/DEPARTMENT USE ONLY '
Disapproved Sanitary Permit Fee (Includes Groundwater Date issued issuing A ent Signat No Sta y
~
Approved ❑ Owner Given Initial `f w r : Su barge Fee
) Adv rsa Determination
~~•-%Q
X. CONDITIONS OF APPROVALIREASOrffS FOR D,ISAPPROVfA/Ict ♦ / i ► J~
Y", '
A
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
Oar
10- 0
iVN~rvl ~~M'~~G to SaX`~~~
g' J
~JV,('v
UK 161OLOO
~j Fro n, t,) t 4
Vi6lation Number Form - S T C - 101
PRE SANITARY PERMIT ISSUANCE PROCEDURE
Location Section Townshi Lot No. Blk. No. Subdivision
~!)C_~41 f I 0141 j IT p9 N/ R/6 W 1 ~o~~l r~ 1 I
Procedure prior to sanitary permit issuance where a septic tank must be replaced
during winter weather or other health emergency and soil evaluation or other sys-
tem evaluation cannot be conducted.
1. Obtain assurance that the property owner is aware of further requirements
for a system evaluation.
2. Obtain assurance that owner is aware that if system is found to be
failing, it will be their responsibility to replace it with a code
complying system.
AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY PERMIT:
I, O&AC:L ad,j& ~Q,-%. , the undersigned do hereby acknowledge
that I am receiving a sanitary permit to
without a soil and system evaluation due to inclement weather o health emergency.
Furthermore, I acknowledge that a soil and system evaluation will be conducted
as weather permits and that if the system is then found to be failing as defined
in Section I L H R 83.02 (18), Wisconsin Administrative Code, it will be replaced
with one that complies with Chapter I L H R 83 of the Wisconsin Administrative
Code. If temporary pumping is to be utilized for maintaining a newly installed
septic tank, due to failure of the system, the tank shall be maintained by a
licensed pumper in accordance with N R 113, Wisconsin Administrative Code.
SIGNED-~--'
DATE
A copy of an affidavit in lieu of EH 115 along with the PLB 67 must be submitted
to the Plumbing Bureau for 'purposes of fee reimbursement.
~r C
Signature o pplicant Date
Subscribed and sworn to"before me
STATE OF WISCONSIN This day of 19
SS.
COUNTY OF 'k~
Notary lic, State of "_W~Lisco//nsin
My Commission Expires : , Gv, /99~
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