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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER '
TOWNSHIP_ z-/`j ~
SECTION_.~~T 30 N-R~ 7W
ADDRESS
ST. CROIX COUNTY, WISCONSIN
e V- Gam` ~~aa
SUBDIVISION - LOT ----LOT SIff-
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTE
D fh S
r
I~ s®~
r
1,21
~chf
INDICATE NORTH ARROW
BENCHMARK: Elevation and description:
~f'u G, ~t~~sfU ~r
Alternate benchmark,
SEPTIC TANK:Manufacturer: laQl~ !j Liquid Cap. /
Rings used: 'Manhole cover elev: Final grade elev:/0r'/
Tank inlet elev.: 3 Tank outlet elev.: <`:9 '
No. of feet from nearest road:Front
Side , Rear Ft. S z~
From nearest prop. line:Front--/-<, Side , Rear Ft. 31,u~
No. of feet from: Well 1 il- Building: /
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front_, Side_, Rear-Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
r
Width :Length 1` Number of Lines:_ Area Built
Exist. Grade Elev. , Proposed Final Grade Elev.
Fill depth to top of pipe:
i
No. feet from nearest prop. l' :Front' Side , Rear Ft .
No. feet from well:^ f'(/ No. feet from building f
all
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
Wisconsin Department of Industr, O /
Labor and Human Relations y PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division INSPECTION REPORT St . Croix
1 I-, AAe'F ~SH1T~ f ~R1T) Sanitary Permit No.:
GENERAL INFORMATION NE4 , NWe , OL. 149221
Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.:
Brad Wittig Erin Prairie
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
385B 012-1055-10
TANK INFORMATION ELEVATION DATA 2 171
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic r
0_6e Jic. Te Benchmark 66
Dosin _ 0, :Z, ~o i
Aeration Bldg. Sewer
Holding St/ Ht Inlet 3Z/
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
Do NA Header 3 _23
Aeration NA Dist. Pipe ,SD 97,06
Holding J Bot. System T. 96,
PUMP/ SIPHON INFORMATION Final Grade q,~~
Man cturer Demand ST' I K~k Q S6
Model Number GPM
TDH Lift Friction S stem TDH t
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 S DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
Model Numbe
INFORMATION Type CHAMBER
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Marrifu'd Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length rz, Dia. Length ~S 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.)
J
Plan revision required? ❑ Yes [~1Vo
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signa ure Cert No.
„ D LH MMMI SANITARY PERMIT APPLICATION
LPIn 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 / 0, / C7 /1 ~7
8% x 11 inches in size. ❑ Chick ff revisioOnlto0p eJlOus application
wee reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OW ER PROPERTY LOCATION
y '/a,S T o,N,R E(o
PROPE - % WNER'S AIL! G ADDRESS LO BLOCK #
a`-
CIjY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
t Ith 2 / s
El TY
❑ p NEAREST ROAD
11. TYPE OF BUILDING: (Check one) El State Owned
VILL. GE
Public A or 2 Fam. Dwelling-#~ of bedrooms ~ AR EL x NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) 3RT 13 61;2 J
_
loss- - /6 60C)
1 El Apt/Condo r
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home' 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. Q~ New 2. ❑ Replacement 3.E1 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 eepage Bed 21 E1 Mound 30 El Specify Type 41 El Holding Tank
12 Seepage Trench 220 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
< . / 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 structed 51
Septic Tank or Holding Tink ~bD $
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's nature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Z-4 JJrQ ~7 18011%4,
. 4f~ _-7 1
Plumbers Address (St
reet, City, State, Zip Code): _
...01 . Ax.,
d X s. cam
IX. COUNTY/DEPAR MENT USE ONLY oool'
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial 4- Surcharge Fee)
Adverse Determination I I/ L15- LK -yl --9
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
• STC-100
This application form is to be completed in full and signed by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property I~acF ~e P• 4'l~ t
Location of property_E:~W k!L/l/4, Section Zs , T 3 D N-RLW
Township Fr~.) A-d ;r-i C
Mailing address _ 2-r L; DjVisiOh ki/ -C~,6LpZ2
Address of site 1 o G'xr 4 v-c Of 2
Subdivision name Lot no. 1
Other homes on property? yes No
Previous owner of property
Total size of parcel-? 3.,5 d 6 ~GlPf
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes „LNo
Volume and Page Number as recorded. with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
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 owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded i]$he office of the county Register of
Deeds as Document No. 4 //~f2 , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No.
Sig4te
of a
pplic t Co-applicant
bate of Signature'
Date of Signature
<_f v .:fit •
a~ , r ~~*S 1e
H• Harris
'go
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wimonts to
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UW foOpwing 49MOOd 1 male fit ~ `
stile of lliiseq~
Bast UaLf of Ifort,
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96 teatca to ~rlrer of t ~
spa.,.' Po~t.: at
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. *t thence N 03°50' 20" U.:6
not
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400 .09
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y
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54402
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~aQ I P?M
ADDRESS: I ~U FIRE NO:
LOCATION : ~ l Z 1/4, SEC. 2-67- T 30 N-R~W,
TOWN OF : _ Er t (I P /tea ST. CROIX COUNTY W-Z~
SUBDIVISION: LOT NO.
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.
SIGNED:
I /
DATE :
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,' DIVISION BOX HUMAN LABORAND PERCOLATION TESTS (11J) MADISON WI 53707
ILHR 83.0911) & Chapter 145)
L ATION: SECTION: TOWNS /MUNICIPA~LITY:OT NO.:BLK NO.: SUBDIVISION NAME:
X V1/1 /T oH/ E (o i r _
CO N MAILING ADDRESS:
I_ .7 - 1 .l"
USE DATES OBSERVATIONS MADE 6
150 NO. BEDRMS.: COMMER IAL DESCRIPTION: A EST
Residence New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEQM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S 0U 5KS oU S E1U 0 J U EIS ZU
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the ,~/fyy
under s. ILHR 83.09(5) (b), indicate 1Z Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL PTH 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.)
B- f gut > 7
B- =i
J
B-3 /
A-C
22
B-
PERCOLATION TESTS
EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L VEL-INCHES RATE MINUTES
NUMBER IAIAIES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ %
P-
P-
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. I? ZL
S STEM ELEVATION ~e.
,
:
E ;
w~_ - - e f
Iva-
J` 3~r.. loo riy? _ 30A
a
~e
J~
E ,
3
.
i I
E f
3 3
-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 t'2 "7 1 ' TESTS WERE COMPLETED ON:
A(J
ADDR CERTIFICATION NUMB : PHONE NUMBER (optional):
CST SIGNAT E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
PLOT PLAN
PROJECT r ~/I ADDRESS
,,--.134 N/ /7W TOWN _yti C COUNT( S1~ Gro~y
MPRS Byron Bird Jr. 3318 DATE o -
BEDROOM, CLASS PERCH CONVENTIONAL- IN-GROG PRESSURE
CONVENTIONAL LIFT- MOUND- HOLDING TANK
SEPTIC TANK SIZE zc-~~LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE -4z? BED SIZE
► Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
* H.R.P._
O:Borehole Q Well Scale Feet `
O Perc Hole System Elevation
Uent
12"
Gradp
TYPAR COVERING
2-
12- 3' 4 8' O 3' 3' 0 3'
Sewer Rock
6
12' 18'
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