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~-&EPA'RTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: PXADENIUMUCKMI: LOT NO.:BLK. NO.: SUBDIVISION NAME:
1N,E 1/4 NE 1/4 2 /T30 N/R 18lix-r) W Richmond n/a n/a n/a
COUNTY: OWNER'S E: MAILING ADDRESS:
St. Croix Jeff Lauck IR.R.A, New Richmondc Wi. 54017
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILEDESCRIPTIONS: PI~Residence 2 n/a ❑New Replace Il 11-1-90 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
9S ❑U ❑ S ®U CAS ❑U ❑ S EU ❑ S lau conventional
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
class 2 n/a
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
decimal' PROFILE DESCRIPTIONS page 28 ShB
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 7.17 103.49 none >7.17 .75bl.1. 1.50bn.sil. .92bn.l.s. 4.00bn.s.l.
B 2- 1 7,17 103.34 none >7.17 1.00bl.l. 2.42bn.sil. 3.75bn.s.l.
B 3 7.42 102.76 none >7.42 .67bl.1. 1.50bn.sil. 3.00bn.l.s.&gr. 2.25bn.l.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 PERI05 T__ PER INCH
P-
H eslgn rate
PLOT T 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 99.76
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3
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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 11-1-90
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Wi. 54017 2298 1715-A446-6200
CST SIG E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
T )RM - STC - 104
11
AS BUILT SANITARY SYSTEM REPORT
OWNER ` Gccc ~l1 G~~'ri . TOWNSHIP
_j~ SECTION T_N-R~W
ADDRESS ox n? e eq- ( 13M 1+~T1~ ~ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT 'MOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
D~
fit`"
S3~
aj
l-s ` s
INDICATE NORTH ARROW
BENCHMARK:Elevation and description:
u~c ®T uJrt
TAlternate benchmark
SEPTIC TANK: Manuf acturer : e e fi5 Liquid Cap. Oa ~l
Rings used: Manhole cover elev:'/oo'/ Final grade elev: OC' 7
Tank inlet elev.: Tank outlet elev.: K. 41 Z
No. of feet from nearest road:Front-I-,, Side , Rear Ft.67
i
From nearest prop. line:Front , Side , Rear ?k Ft. -4i
No. of feet from: Well f Building:_ ~ r'
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
t
r
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:
Width: Length Number of Lines:- ,Z Area Built- w1jV~
Exist. Grade Elev. AP/. ~7 Proposed Final Grade Elev. - gyp /
s
Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side , Rear Ft.y~-'
No. feet from well:__A6,(f,2 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 : ~1
LICENSE NUMBER:
6/90:cj
Q(
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT St. Croix
Safety and Buildings Division NE NE 2 3 0 18W
' ' ' ' T Sanitary Permit No-,
GENERAL INFORMATION County ( TTACH TO PERMIT) 149214
Permit Holder's Name: ❑ City ❑ Village 0 Town of: State Plan ID No.:
Dan & Paul Garrity Richmond
CST BM Elev.: Insp. BM Elev.: 77 Description: Parcel Tax No.:
4110- 1 ,6 026-10052-000 17B
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic SC Benchmark
640" 166,616 1
Aeration Bldg. Sewer
Holding St/Ht Inlet .3TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Septic J!' a NA Dt Bottom
NA Head er4- 9 7
II
Aeration NA Dist. Pipe 20
Holding Bot. System 16.600, rf
PUMP/ SIPHON INFORMATION Final Grade s D , a
Manufacturer Demand``"
5 . , Caves . Gi (1C~r M
Mod umber GPM ,G t` 3~
TDH Lift Friction stem TDH Ft
Forcemain Length Dia. Dist.
SOIL ABSORPTION SYSTEM
BED/TRENCH Width, r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS a DIMENSIONS
Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING
INFORMATION TypeO CAY~ - I r CHAMBER Model Number:
OR UNIT
System:
skd A14_
DISTRIBUTION SYSTEM
Header/ fdFarriivld Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
19 >
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over ~c of xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges ~U Topsoil E] Yes No [I Yes El No
COMMENTS: (Include code discrepancies, persons present, etc.)
o f a axtaqq
6,77 q 3-5'
Plan revision required? ❑ Yes 2'1q_0
Use other side for additional information. ?0 /O WAA
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
Z
SANITARY PERMIT APPLICATION
:EQ&HO In accord with ILHR 83.05, Wis. Adm. Code COUNTY
16 STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 1
8% x 11 inches in size. c eck f Y.R., to pre ious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROPERTY LOCATION
j`%)J t/a, S T N, R
P
P ROPE OWNERaQZ;R LOT BLOCK #
CITY, STATE - ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
g w. oz 7 L 7 -
II. TYPE OF BUILDING: (Check one) CITY AREST ROAD
❑ State Owned VILLAGE
❑ Public 1 or 2 Fam. Dwelling- # of bedrooms EL X NUM R() 1-~
Ill. 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
i~
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. ,4 Replacement 3. ❑ Replacement of 4. ❑ 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 eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 IJ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
Vl. 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
QU sq. ft.) PROPO ft.) (Gals/d /sq. ft.) (Min./inch) ELEVATION
hT7O Feet e,;7 ? eet
VII. TANK MPACITY Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank
El 1 1:1 El
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' ame (Print): ) Plumber's 'gnature: (No Stamps) MP/MPRSW No.: Business Phone Number:
-a
Plu s Address (Street, City, State-, Zip Code
~ltCs-
IX. C UNTY/DEPARTM NT USE ONLY
❑ Disapproved Vary Permit Fee (Inuluharg roue water a e ssue Issuing A ent Agnew
Approved ❑ Owner Given Initial ~l /
Adverse Determination C;
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
r
INSTRUCTIONS
J
y ~
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 perrnit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (;BBD 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 E.dministrator 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 end complete # of bedrooms if 1 or 2 Farr ily 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 gallcns, 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 tc 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; fr ction 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)
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/contractpr,("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
AA il,41L
Location of Property Section T N - R 1,A, W
Township
Mailing Address A,,Y
A
Subdivision Name
Lot Number
Previous Owner of Property J e C
Total Size of Parcel .l QGr
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number. 2-a as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
01. Warranty Deed
2. Land Contract
3.• Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) CvLti.6y that at t dtatementa on thiA 6on.m cute tn.u.e to the beat o6 my (our)
knowtedge; that I (we) am ( cute) the owner (6) o6 the pnopeh ty deb m bed in th.i,e
in6onmati.on 6ohm, by viAtue o6 a waw.a.nty deed %econded in the 066ice o6 the
County RegiAteA o6 Deedb a.6 Document No. l. ~ , and that I (we)
pneaentty own the p4oposed Aite 6oh the sewage pob eydtem (on I (we) have
obtained an eabement, to Aun with the above de6cA bed pnopenty, bon the
conexhucti.on o6 bai.d Aydtem, and the same hab been y heeohded in the 066ice
o6 the County Regi4ten. o6 Veed6, ab Document No.
x
SIGNATURE(Gi OWNER SIGNATURE OF CO WNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
J
A F siVi T +L. ..}w... aY•1.f.dYR W~; . _
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SEPTIC TANK MAINTENANCE AGREEMENT H
0
St. Croix County z
d I
Jai a
OWNER./.BUYER M
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP SC'~S
PROPERTY LOCATION:&6k, ...jV(~-14, Section_, T -3c) N, R /25 W,
Town of IV0, R'y;' , St. Croix County,
Subdivision Lot number
I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists 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 treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master 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-
essary), the septic'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. Ho
I/WE, the undersigned, have read the above requirements and agree En
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Of ice within 30 days
of the three year expiration date.
SIGNEl f4,,uk &,6M
DATE Z
St. Croix County Zoning Office
P.O. Box 98'X
Hammond, WI 54015
715-7<96-2239 or 715-425-8363
Sign, date and return to above address.
J~
14
'[LIAR IMLr: ( 01' - REPORT ON SOIL BORINGS AND SAFETY 8( HIM DIN(iS
IN 1)1JSTHY, DIVISION
AND P.O. BOX 79139
PERCOLATION TESTS (115) MADISON WI 53107
I LABOR
It1MF~l'J HE
RWA~
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TUWNSHIPD6AI~F~PP)4B1~Q~: LOT NU.: BLK. NO.: SUBDIVISION NAME:
NE 1/4 NE 1/4 2 /T30 N/R 18Ey,,) W Ricluti n/a n/a n/a
000NTY: OWNER'S fU6Mli~6AE: MAILING ADDRESS:
St. Croix Jeff Lauck R.R.#4, New Ri.chmondq Wi. 54017 _
USE DATES OBSERVATIONS MADE
_ 1CiN l ES "I
PROFIL~~~CIONS: PEi~COLA1 S:
NO.BEDRMS_COMMERC-iAL DESCRIPTION:I
Residence 1 L.~New kAReplace 11-1-90 i-iIPT- n/a
L- - 1 n / a -
RATING: S= Site suitable for system U= Site unsuitable for system i
LL BOLDING TANK~RECOMMENDED SYST tional)
:ONVEN fIONAI..: MOUND: iIN-GROUNDPRESSUV ET. 3 TEM-IN. FI ti
x x conventional _
XS Flu o s ®U 1-- us ou n s 6du 10 s ~u_l
-----------DESIGN RATE: -
It Percolation Tests are NOT required r class 2 If any portion of the tested area is in the
L111110 Floodplain, indicate Floodplain elevation: n/L111110 s. I LHR 83.0915111)1, indicate
decimal' PROFILE DESCRIPTIONS page 28 S1IB
BORING TOTAL D P111 TO GROUNDWATER-INCHES CHARACTER OF SOIL. WITH THICKNESS, COLOR, TEXTURE, AND DEi' I H
NUN4BLH DEPTII ( ELEVATION --OBSERVED---. EST. IGHEa, TO BEDROCK IF OBSERVED (SEE ABBRV_ ON BACK.(
B- 1 7,17 103.49 none >7.17 .75bl.1. 1.501bn.sil. .921)n.l.s. 4.00bn.s.1.
B- 2 7.1.7 103.34 none >7.17 1.00b1.l. 2.42bn.si_l. 3.75bn.s.l.
B 3 7.42 102.76 none >7.42 .671)1.1. 1.50bn.sil. 3.00bn_l.s.&gr. 2.25hri.1 _s.
B-
B-
PERCOLATION - -
TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L.E_VEL-INCHES UT-RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PEgl00 2 PERTiS - PER INCA
P
- - -
,,see esi n rate
P.
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are ilia hori-
zontal and vertical elevation reference (mints and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
99.76
SYSTEM ELEVATION
EM ELEVATION _ n
Ifto lid 4V ~A
i 2 oil
JCL i }A b1 JZ t'~'~ Fl I I j ~l' t N
~ys 17
co lk~
4/ I j
1, then w,daroianad, hataby certify that the soil toots raiiottrtd r9r, This form were matte by tire in accard with the praoudutus and rnotlinds slrucilied 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:--
Oivfir " stool 11-1 -90
w{ r+ S
s~F T
C~sf`a►l~I~~~1~i~f~, .-~fr)IllflliglT:
~I~~)I'~~~' LLLLL
J."')Ii 7.(")()I:lt. Ave.) meow 1W3111110tit1, Wt , 51,0111 2911
BUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
-
D 6395 (R. 10/83) _ --OVER
" PROJECT ADDRESS
TOWN COUNTY
MPRS Byron Bird Jr. 3318 DAT p
BEDROOM 9 CLASS PER .--CONVENTIONAL- IN-GROUN ESSURE
CONVENTIONAL LIFT- MOUNDY HOLDING TANK
SEPTIC TANK SIZE IFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE G 3~f) BED SIZE
1L Benchmark V.R.P. Assume Elevation 100' --7~~~-
Location of Benchmark
* H.R.P.-
0:Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
Vent
12"
Grnde_
TYPAR COVFRINr,
2"
12" 3' 4 6' O 3•
Sewer Rock
6" l
12'
Co
C
O l,' Syr
to -3