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~~aOG
AS BUILT SANITARY SYSTEM REPORT
OWNER l~~ I1 N ~M ~A~ 1 TOWNSHIP RU v_SD ~,3
_U
SECTION U T _N-RL
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
RS
Bay
4e ~
as
6/ ,ao 1
A II''
41
OOD R 00
INDICATE NORTH ARROW
~Ns'~I~'IoY~
BENCHMARK: Elevation and description:
Alternate benchmark 1
SEPTIC TANK:Manufacturer: Ije e 14 S Liquid Cap. W00 Au
Rings used:i Manhole cover elev:Pb Final grade elev:
Tank inlet elev.: Tank outlet elev.: 9 5 S U
i
No. of feet from nearest road:Front , Side , Rear Ft.I U
From nearest prop. line:Front , Side V , Rear Ft. 13S/
No. of feet from: Well I G D , Building: D
(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 Q
S~o y av vv 'HTDP_i'~. I~.~C~ ~ 7~•Q~
SOIL ABSORPTION SYSTEMv ~1^r la 9 I.83 ' ~.$3
Bed: Trench: Seepage Pit:
Width: 18 Length S Number of Lines:-3-_Area Built_9 7c~
Exist. Grade Elev. Proposed Final Grade Elev. 5.33
Fill depth to top of pipe: 4~
No. feet from nearest prop. line:Front SideBa,, Rear Ft.
No. feet from well: c~03i 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:
Q Q INSPECTOR:
DATE : 1 I PLUMBER ON JOB : Qv~-
LICENSE NUMBER: 3 U
6/90:cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor And Human Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
(ATTACH TO PERMIT) sanitary Permit No.:
GENERAL INFORMATIONNEt - NW sec. 20 T28-R1 9 Co.Rd A 149188
4 / 4
Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.:
Marlin Amdahl Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
~,0~~ 189C
TANK INFORMATION ELEVATION DATA 9 /
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /At 2, !rS
Aeration Bldg. Sewer
Holding St/ ,Wt Inlet G a r
TANK SETBACK INFORMATION St/, rK Outlet 7, OZ/
TANK TO P/ L WELL BLDG. Vent to ROAD AA-FntaT
Air Intake
Septic 7/ jXj l NA DL Beni
NA Headed Osm..
Aeration NA Dist. Pipe /0,62,
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade 't Z 27, 9'
Manufacturer Demand 17 Ve.- lid GtJJ.8~5
Model Number GPM
TDH Lift Friction stem L TTDH Ft
Forcemain I Length Dia. Di well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length / No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S DIMEN I N
Manufacturer:
LEAC
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION TypeO Co-nv-CHAMBER Num er:
System: arl-d w,LJ, CP~ > OR UNIT
DISTRIBUTION SYSTEM
Header /-M*R4eW- 7( Distribution Pipe(s) , x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. `f 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
i
Bed/ Trench enter t10 -~Q Bed/TrenchE ges y0 - v Topsoil E] Yes ❑ No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
/12
Plan revision required? ❑ Yes 9'1q-0
Use other side for additional information.
9l /
12
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
' s
SANITARY PERMIT APPLICATION
I'ZIDILH R I n accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE S IT RY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ lq7 j Q'P'
8% x 11 inches in size. check if revision o previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY NER PROPERTY LOCATION
M.p2 Nj C, N f t/a %t, S T 9, N, R E (or)
PROPERTY OWNER'S MAILI DREScL LOT # KIA BLOCK # n )
PITY, STATE ZIP CODE PHONE MBER SUBDIVISI N N ME OR CSM NUMBER /
VAV0 -aN S11 1
C,r
CITY NEAR T ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : ~_y o
` R
❑ Public E41 or 2 Fam. Dwelling-# of bedrooms _q PARCEL TA NUMBER(S)
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) 1. ❑ New 2. EgReplacement 3. ❑ Replacement of 4.E1 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 430 Vault Privy
14 ❑ System-In-Fill
V1. 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.) PR SE (s ft.) (Gal//s/da /sq. ft.) (Min./inch) RELEVATION
C b , 0 . 7a 100 Feet 1 ~ • 3 0Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank Poo L4a_=.= I Fj I F] 1 0 1 11 1 1:1 1 1:1
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.
Plumb Name (Print): Plumber's Sig a re: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City State, ip Code)
110S M)a~, A sofa > ~_r
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
/ Surcharge Fee)
0 Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
APPLICATION FOR SANITARY PERMIT
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 RAe-41A) V_ lga-l;~4 1 ~ /7 L-
Location of property X1/4 W 1/4, Section a l> , T N-R~W
Township 4 L(D ~ 0 N U) I gC.
Mailing address A - Q~nLm Address of site
Subdivision name
Lot number
'+~~h-~-
Previous owner of property
Total size of parcel-
Date
parcel was created ~ C;rc) Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for resale (spec house)? Yes ✓ No
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, and
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 de d recorded in the Office of
the County Register of Deeds as Document No. ;?Q_; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Regist of De Is, as Document No.
a,-,- Signat re of 0 er Signature of Co-Owner (If Applicable)
7 7/
Date of Si ature
Date of S gnature
SEPTIC TANK MAINTENANCE AGREE11ENT
St. Croix County
11 - WiL
OWNER/ BUYER l~'I 1q fLt- t' g+m 7 ft 14
lN 0
0
Fire Number
ROUTE/BOX NUMBER
S
CITY/STATE -C' ZIP
Section-011-0 T2±_N, R._LW,
PROPERTY LOCATION :..:k)&
Town of N St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by alYeCts~tdeseunctiontank
treat-
o. tmeesepticttank astainto
the system can a
ment-stage in the waste disposal system.
St. Croix Count residents-may be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whit was in operation prior to-July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their system properly
maintained.
The property owner agrees to.submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
)sformcwillkbessentsapthan 1/3 proximatelyl30fdaysdpriordtoc~.
Certification three year-expiration. y
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as.set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration. date.
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
IJEf'Q.RTME,NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR
P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: rOWNSH P OT NO.: BLK. NO.: SUBDIVISION NAME:
1/4w4/ Zo yT29N/R1E (o
TNTY: OWNER'S BUYER'S NAME: MAILING ADQXESS:Y / <W GL~I SY61
USE Vy CC//,'~~11FF// DATES OBSERVATIONS MADE
NO. BEDRMS.: ICOMMER SCRIPTION: PROFI DE RIPTIONS: IPERCOAAT!PN TESTS:
esidence ❑ New Replace ~ G
RATING: S= Site suitable for system U= Site unsuitable for system
t
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: US EM-IN-FILLHOLDING TANK: RECOM~VIENDED SYSTEZ:Z/
❑U S DU 1EJS,8U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 3 455 ~ Floodplain, indicate Floodplain elevation: A-114
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 1s0 ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE BBRV. ON BACK.)
0'611-T ` 2, S Yl S.Ste: r S ~i'l S
B- D ' /!r f` d/sr,7 Q17 5 ~nS
B- 19f 21 S Brr~s
1 r
B-
B-
-B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER =T AFTERS WELLING INTERVAL-MIN. PERIOD 1 PE OD 2 P PER INCH
P_ 2 .3
P_ Z- S/ 7 L 4~ 3
P- v 4 3 10/ W
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
orland slope. r
SYSTEM ELEVATION _
3
7_T+
E
VJ 11,
R~ -
line,
H
E
J3''-4
I ~4 p _
lD t
_J R~
x2 ~s~
I '
I
3
E - .
l 13 1
the undersigned, hereb
y cert Y that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
pministrative Code, and that t e data recorded and the location of the tests are correct to the best of my knowledge and belief.
AME ( rint : TESTS ER OMPLETED ON:
h
DD SS: CE 1F1 ATION NUMBER: PHONE NUMBER (optional):
Ay _
-y -17 Q C 57 003-
CST SIG p
CTRIBUTION: Original and one copy to Local Authority, Property Owner an of ester.
'-SBD-6395 (R. 02/82) - OVER -
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FRESH AI12 INLETS AND OBSERVA'PION PIPE
CI;OSS SECTION
Approved Vent Cap
Minimum 12" Above
Final Grade-- rvx; f,~fy l.o
4" Cast Iron
Above Pip Vent Pipe
i To Final Grade,
~t
Marsh Ilay Or Synthetic Covering
i Min. 2" Aggrey-11 o _
Over Pipe
Distribut-io 7~ I
Pipe
A ~
Aggregate Perforated Pipe Delow
i , I)enc temps e Coupl.ing Terminating T
Bottom of System