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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR Ir~ SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number:
SW, SE, 2 7 , 3 6 , 19W [CONVENTIONAL El ALTERATIVE (It assigned)
Town of St. Joseph ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
Co NA ; PE IT HOLDER ADDRESS OF PERMIT HOLDER: INSPECTIOV DATE:
Steven w el 1 36 Pine Wood Lane Hudson WI 1_4Pi 02 9
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: 5401 V.. T REF. PT. ELEV.:
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Name of Plumber: MP/MPRSW No.: CountY San' a ber:
William S humaker 6382 St. Croi 49018
SEPTIC TANKA406DING TAW;(,
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELE K OUTLET E WARNING LABEL LOCKING
PROVIDED :COVER
~ PR~OVIDED~
C (/'z. C'1?C~ 7•J 7.3 .3 L~'fES ❑ NO ❑ YES
BEDDING: -VENT DIA.: VENT MATL.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT T ESH
C-, o C- c ALARM: FEET FROM LINE~~ ( ti/~/ AIR INL T: A
❑ YES O ❑ YES NEAREST
MANUFACTURER: B ID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER- WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS O ONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO 1EAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENG DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.
CONVENTIONAL SYSTEM: S {e = 3
WIDTH: LENGTH: NO. OF DIS R. PIP SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH / TRENCHES: / M AL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. IPE AT RIAL: NO. I TR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELO~N PIPES: ABOVE COVER: E EV. INLET: ELEV. END: PIPES: FEET FROM LIN ~,l AIR INLET:
~JV/
117-3 63 rrS it NEAREST
MOUND SYSTEM: 17 ; X/
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope an s thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO. OF LATERAL SPACING G L DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/TRENCH
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: ISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPE DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION 'PROVED PLANS
❑ YES ❑ NO YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY BUILDING:
COMMENTS: FEET FROM LINE:
~S ~L t7C,.(~ C~' ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
etain in county file for au it. ,
Sketch System on
Reverse Side. SIGNAT RE: TITLE:
Zoning Administrator
SBD-6710 (R. 06/88) a'}
SANITARY PERMIT APPLICATION - 7In accord with ILHR 83.05, Wis. Adm. Code
. e.....,...
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than - '?o '
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.
PROPERTY OWNER PROPERTY LOCATION
,S7'euf,,1 `W %SO%, Sa-7 T&a, N, R / E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
W~Le,4 lei/
CITY, STASO~ ZS CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER "
_0 TY
II. TYPE OF BUILDING: (Check one) 1:1 State Owned VILLLLAGGEE : N A ROAD
X1 o OF: ❑ Public 44L1 or 2 Fam. Dwelling-# of bedrooms,- PA RTOWN A U TR( Q3D _~o
III. BUILDING USE: (If building type is public, check all that apply) 70 ` ! ®r a .7Y~
1 El Apt/Condo •T
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 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. ❑ 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 0 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
S REQUIRED (sq. ft.) PROPOSED (sq. tt.) (Gals day/sq. ft.) (Min. inch) ELEVATION
Al O .S ht; Y 00 y® V11 ~ye. .0 Feet Q3. 83 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 00 L
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/ PRSW No.: Business Phone Number:
c
jl.ra~ s1yKX.s*,V4- ~ /a ir
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing gent Signature (No Sta )
L urcharge Fee) 4,3
Approved ❑ Owner Given initial # [1 1
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FO ISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber
t
1
APPLICATION FOR SANITARY PERMIT
S'TC - 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 5~rtws.~.~
Location of property ~ ~ 1/9 /4, Section T Z _N-R W
Township ~f i C'ue'
Mailing address ~anc A/0 <-Dn 0/
Address of site ~Q ~T Jat C
r
Subdivision name N,4
Lot number /V, 4 60-e -.5-8'I
Previous owner of property Adf k & r/ Je
Total size of parcel bey ~crr,t
Date parcel was created L ' $
Are all corners and lot lines identifiable? ,X Yes No
Is this property being developed for resale (spec house)? Yes ._N0
Volume FS-S and Page Number y,?2 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 deed recorded in the Office of
the County Register of Deeds as Document No. Y m: 7L ; 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 Register of Deeds, as Document No.
Signature!' Owner Signature of Co-Owner (If Applicable)
Date o Sig ature Date of Signature
tea 66
ty
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER . 'k t-1WtFr-: i0
ROUTE/BOX NUMBER 1036 0e1 ye-- &,r c, e a- h o-il FIRE NO.
CITY/STATE C~/~-o~~ c~•J 4,/ a ZIP -17/al (P
PROPERTY LOCATION: -'--14'J 1/4 1/4, Section 2 7 , T 30" N, R / W,
Town of C7 0' as e,4--! , St. Croix County,
Subdivision C6m ✓o~_, 2 T~ , Lot No. C~
-rV
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 for a MAXIMUM of
$3000 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 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 form 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 Department of Natural Resources. Certification i
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
I
SIGNED _ ,j . JcLc'1 \1^
DATE 7
r
St. Croix County Zoning Office
St. Croix. County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
o
INDUS
DEPARTMENT -OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , C DIVISION
LABOR AN P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
BDIION NAME:
SU
LOCATION,:s SECTION: TOWNSHIP/bF~PJ+6i+R4: LOT 71BLK.
/4 Z 7 /T ■ 5I / / b(or
COUNTY: OWNE S BUYER'S NAME . j MAILING ADDRESS:
SLI l.►ro~ SUL' ~n/L+'~Gl fo GJOOj
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMER I L DESCRIPTION: PR FI D P IONS: R I TESTS:
Residence 3 New ❑ Replace O D
RATING: S= Site suitable for system U= Site unsuitable for system
r O VENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SY TEM: optional)
_N S ❑U ®S ❑U f~'S ❑U ❑ S (~'U D S &)U ratite
If Percolation Tests are NOT re uired DESIGN TE:
Z7 JS If any portion of the tested area is in the
Q
under s.H63.09(5)(b), indicate: ~ ` / Floodplain, indicate Floodplain elevation:
,r PROFILE DESCRIPTIONS
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.)
/ l
B- SS n,~ l 5 y $3
i
s' 3/~ 33 ans S 7 /Sh 57/6
B- Z o a /0531
yz 77, :Z. Y2 - / yi7 ~Brys
B- g o ~d y~i
175'141~ 2.
B gl7 Jny >
B-
PERCOLATION TESTS
TEST DEPTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PE I D2 PERIOD PER INCH
P_ '9
P_ -37V 3 i6
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 AW.3.3
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I, the undersigned, hereby certify that the,soil tests reported on this form were made by me in accord ith 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 (pri TESTS WERE M ETED ON:
ice
CERTIFI TI Qfi N ADDR SS: MBER: PHONE NUMBER (optional):
CST S I T
DtST4I !UTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILI'R-SBD-6395 (R. 02/82) - OVER -
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