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Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER dZF _3 GlYI TOWNSHIP S/, ~70,SE4SEC. Z~ T Q_N-R 'O W
ADDRESS 1386 14&2622 Rg ST. CROIX COUNTY, WISCONSIN
0ac TD N
SUBDIVISION #0at_TQ1'V LOT S LOT SIZE 'Ae/l'S
PLAN VIEW
Distances and dimensions to meet requirements of I•ZHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
CA &EF -/0
p60p
C_
r
C
W
5"J" CIA
sa Ar L,
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 1 d p Q,c /,U'eLL
Elevation of vertical reference point: ,1701.0 Proposed slope at site:
SEPTIC TANK: Manufacturer: Capacity: j 00
Number of rings used: Tank manhole cover elevation: 22
Tank Inlet Elevation: - Tank Outlet Elevation: Number of feet from nearest Road: Front,W Side0 Rear, O - feet
From nearest property line FrontloSide,®Rear,0 feet
Number of feet from: well 32 building:
(Include this information of the above plot plan)( 2 reference dimensions to 'septic tank)
iRO nT[1prl RAF 4!T*+r..
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: _ /I 7 w PuMp/Siphon Manufacturer:
_Z_ OCLL_~/1 Pump Size -Y?g:~Zt _
Elevation of inlet: 90.E / Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle: _ z 9
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, Q Ft.
Number of feet from well: F'
Number of feet from building: '
(Include distances on plot plan).!
SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: / Length: Number of Lines:
Area Built: ZU_
Fill depth to top of pipe:
Number of feet from nearest property line: Front
O Side, ~ Rear,O pt .-100
Number of feet from well: p ACV
Number of feet from building:
(Include distances on plot plan).
PAGE PIT
ize: Number of pits: Diameter:
Liqu depth: Bottom of seepage pit elevation:
Area Built.
Has either a drop box or distribution box O been used any of the above soil
absorbtion sytems? (Check e).
HOLDING TANK
Manufacturer: `
apacity:
Number of rings used: evati of bottom of tank:
Elevation of inlet:
Number of feet from rest property line: Fron O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
44-
Dated: Plumber on job:
License Number : 3267, -
3/84:mj
L
DEPARTMENT-OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
DIVISION
LABOR & HUMAN RELATIONS
P,O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
44 , 4 5, 7S~e c. 2 7, T 3 0- R2 0 a State Plan I.D. Number:
CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of St. Josep~ Lo
Ha ert St. Holding Tank ❑ In-Ground Pressure ❑ Mound
NAM O PERMI HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Herbert Holm 1386 Ha er ST.,Houlton WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM L N: REF. PT. ELEV.: CS REF. P LEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Donavin Schmitt 3205 St Croix 149041
SEPTIC TANK/HOLDING TANK: 7,/ o - 4y. t9~, ~f✓K~
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK O TLET ELEV.: WARNING LABEL - LOCKING COVER
PROVIDE PROVIDED:
~~S Cur's. ~jdf_~ / ~CC~ c l/ Cf~ ES ❑ NO ❑ YES O
BEDDING: k~E1tfDIA.: +1E MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
e 170, ALARM: FEET FROM LINE: [ / AIR IN T'
ea I
S ❑ YES NEAREST ! a o
❑ YES O
DOSING CHAMBER: , 5 h
MANUFACTU ER: BEDDING: QUID CAPACITY: PUMP MODEL: PUMP/ RER: WARNING LABEL LOCKING COVER
P,RRO,VIDED/ PRROVIDW
1 ❑ YES O S'a, ~e3 C'( e I l~f'E5 ❑ NO 1f s ❑ NO
PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL:1 BUILDING: VENT TO FRESH
GALLONS PER CYCLE: LINE: AIR INLET: /
(DIFFERENCE BETWEEN - ~ FEET FROM ti+ rz
PUMP ON AND OFF L!~;lft ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: / DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN OU d(-
the soil is dry enough to continu
CONVENTIONAL SYST : /a,7 13d S 3•
WIDTH: NO. OF DIST . PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH / TRENCHES: / A MAj.WIAL: DE
DIMENSIONS /CP
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. S R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE CpOVEP ELEV. INLET: ELEV. END:I ~ t/ O PIPES: FEET FROM LINE: AI~~INL T'
zi.Z 7C / F ` T YUG NEAREST-11111. 4oO ~OCO /
142
10 MOUND SYSTEM ~ j S/
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows 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 JDS OF TOPSOIL SODDEDSEEDED MULI ❑ YES ❑ NO ❑ YES E] NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING-
-ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YESS ❑ NO ❑ YES ❑ NO NEAREST
e~.//`,S,
C' - _ -
I
tain in county file for audit.
Sketch System on '
Reverse Side. SIGNA RE: TIT
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION
70ILHRO In accord with ILHR 83.05, Wis. Adm. Code couN
~+wm.n s
~ eo~rwwua~.u,w„~w,v~
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. ❑ Cfeck if revision to revious 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
C,IQ QL t/4 A/, t/4, S 27T N, R Z E (or W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/3 9 6 #,46?6 ,t9 T 15 7
CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
W~u i. m r. 5~VR;zi ( -0 : A/17 U L 7 0 /Y
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
State Owned 171
Iff- VILLAGE r -L NA~~~ ST
❑ Public L/~i1 or 2 Fam. Dwelling- # of bedrooms -7- A EL TAX NUMBER (b)
III. BUILDING USE: (If building type is public, check all that apply) 030-,,:7-057-
1 ❑ Apt/Condo J
2 ❑ Assembly Hall 60 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 120 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. USI Replacement 3. ❑ Replacement of 4.E] 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 D9 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 8,20 3 53,h3 Feet Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New F-Xisting Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank 1.2 ,EAE
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): Plumb ignature: (No Stamps) P/MPRSW No. Business Phone Number:
_ a%s s - 6s
cW
Plumber's Address (Street, City, State, Zip Code):
LLB l~IEC~ G~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination /
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
I
APPLICATION FOR SANITARY PERMIT
8TC-100
This application form is to be completed in full and signed by the Ovnet(s) of
the property being developed. Any InadequaCies Will Only result In delays Of
the permit Issuance. -Should this development be intended got resals by
owner/eontcactoe,(spee 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.
-
of
X126 ~ .Z~2e•~ye
Owne property Location of pcope:ty , -1/4 Y~-1/t• section „ 177 _f T -R y
Township -J-O S e,~
Mailing address /3 F6 4 r/Y2,S'
Address of alto I3Sly /fA6 gY2f Oci L to /Va w2 5~0sZ_
subdivision name., 7_- 1/i 11,93 e o F /~aciL four/
Lot number r,-.,
Previous owner of property, - 4A, ole ~tid e ~So
Total also of parcel 0/1/e. AC 2~
Date parcel was created
Are all corners and lot lines ldentltlablet X_Yes o
Is this property being developed tot tesala tepee house)? as 0
Volume „ 03 ,and Pale Number as recorded wlth the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWINGI
A WARRANTY DEED which Includes a DOCUMENT NUMBER, VoLuma AND PAGt NVMan& and
the SEAL OF THS REGISTER OF DEEDS. In additlono a cettlfled survey, It
available, would be helpful so as to avoid delays of the teviring ptoeess. it
the dead description references to a Ceitlflsd survey Map, the Cattlfled survey
Map shall also be requited.
PROPERTY OWNER CERTIFICATION
I(ve) certify that all statements on this form are tsus to the best of my (out)
knowledge; that I (we) am (ate) the owner(s) of tfie property deseclbed In
this lntocmatlon form, by vlttus of a wstsanty doe tecotded In the Office of
the County Registot of Deeds as Document No. ~:212Gt/ ; and that I (Yo)
pcosently own the proposed site for the sevaga disposal system tog I (we) have
obtained an easement, to tun with the above desecibed ptopestr, tot the
constcuctlen of said system, and the same has been duly recorded in the Office
et the Co my Register of Deedsf as Document N -76,101
'113 -L
8 9natuce at Owner 8lgnatuse o[ Co-owner (it J►Pplicablel
~ c
Oats of Signature Data of Signature
TC /0
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County ~
1
OWNER/BUYER ,_2e tie /e, lyd M rt
e 12'~ e l2 7 C 0'
ROUTE/ BOX NUMBER /T~rll2fS~ ~f- Fire Number
Lf r
CITY/ STATE f~o ~ o ~cJ Cc~ ZIP rt
PROPERTY LOCATION:*.~~k,_AZ9-k, Section-a? T.,3_Q_N. RAJ W,
Town of '5 f dose ph , St. Croix County, 84 7 Subdivision ~/dU Lot number✓,IIA-qc- of
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 l'icens'ed' 's'ept'ic tank pumper. What you put into
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 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 'sys't'ems 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-
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. H
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 Depart-
went of Natural Resources, Certification form must be completed
and returned to the St. Croix County Zoning Office wit in 30 days
of the three year expiration date.
DATE 7
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
t1ti7r
SAFETY & BUILDINGS
1
REPORT ON SOIL BORINGS AND DIVISION
DEBARTMLNT'OF - R.O. BOX 7969
MADISON, WI 53707
LALABOR DUSTRYAN`,D , - -PERCOLATION TESTS (115)
HUMAN RELATIONS (1LHR 83.0911) & Chapter 145)
VISION NAME:
TOWNS HIP/4~C~]: LOT NO.: BLK. NO.rH OBDIUltOn
LOCATION: , SECTION: 5 7 rr>
J 27 /T 30 N/R2A(.,) W St. Joseph
AME: MAILING ADDRESS:
COUNTY: OWNER'S/~
St. Croix Herb Holm 1386 Haggerty St., Houlton, Wi. 54082
DATES OBSERVATIONS MADE
USE PROFIL D S RIPTIONS: ER O ATI N TESTS:
NO.BEDRMS.: COMMERCIALDESCRI: ❑New 7~~e:pfa:] 4-10-91 4-10-91
{Residence 4 n/a
RATING: S= Site suitable for system U= Site unsuitable for system cl. #559 tax# 030-2057-95
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEMIN-FILL HOLDING T?NK'RCOIIVentlOnalTEM:(optional)
1
®s au cis ❑u a s au ❑ s BU S ,~rA
T : If any portion of the tested area is in the n/a
DESIGN RATE
If Percolation ests are NOT required
Floodplain, indicate Floodplain elevation:
under s. ILHR 83.09(5)lb), indicate: n/a
decimal' PROFILE DESCRIPTIONS page 41 BxB
BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICK NESS, COLOR, TEXTURE, AND DEPTH
NUMBER DT TAL ELEVATION OBSERVED S . HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.23 97.08 none >7.23 1.101.1. 1.42bn.s.l. &gr. 4.67bn.c.s.& gr.
ilk B-2 7.08 96.53 none >7.08 1.08bl.1. 1.50bn.s.l. &gr. 4.50bn.c.s.&gr.
B-3 7.25 96.88 none >7.25 1.90b1.l. 1.33bn.s.l. &gr. 4.92bn.c.s.&gr.
B-
B-
B-
PERCOLATION TESTS
decimal' DROP IN WATER LEVEL-INCHES RATE MINUTES
TEST DEPTH WATER IN HOLE TEST TIME PER INCH
NUMBER S AFTER SWELLING INTERVAL-MIN. P R1 60D t PER160D 2 P 6 ~3
P_ 1 4.05 none 3 6 6 <
3.50 none 3 6
P_ 2
none 3
P_ 3 3.85
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 - j
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4t tkAll 0"i I
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(04, ' tN
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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.
TESTS WERE COMPLETED ON:
FADDRESS: E (print): (I_10-C~1
y L. Steel CERTIFICATION NUMBER: PHONE NUMBER (optional):
715-2 6-6200
4 200th. Ave., New Richmond, Wi. 54017 CST SIGN E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
-OVER -
DIl_HR-SBD-6395 (R. 10/83)
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DRAWZA~
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77-7
~Y PUMP CHAMBER CROSS SECTIOU AMD SPECIFICATIOUS PA GI, CF
VENT CAP
`'C.I. VEUT PIPE
WEATHERPROOF APPROVED LOCKING
25' FROM DOOR, JUNCTION BOX MANHOLE COVER
WINDOW OR FRESH I2"MIU.
AIR INTAKE I
GRADE
`1" m1u.
I 18" hCl Al.
coNDUtT
18'MIN.
. \ \ 111
INLET PROVIDE
AIRTIGHT SEAL
A
II
I I I
_ I II ALARM
a I II
i I
c *APPROVED i ON
JOINTS WITH
ELEV. FT. APPROVED PIPE I
3' ONTO PUMP OFF
0 SOLID SOIL
CONCRETE BLOCK
RISER EXIT PERMI-MED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPECIFIGATIOAJS
DOSE
TANKS MANUFACTURER: LJJ~c~/C
IJUMBER OF DOSES: PEK DAH
TAMK SIZE: J~~CS GALLONS DOSE VOLUME
ALARM MANUFACTURER: L~11,/' A jA Vtq INCLUDING 5ACKFLOW: j 7 GALLONS
MODEL AIUMiER: DL tl 383
swlrcH Type: _ / CAPACITIES: A= Ic~.y INCHES OR GALLONS
'/~-R
B =__~/_L INCHES OR '4X GALLONS
PUMP MANUFACTURER: -_CtEL i=ce C=INCHES OR 125 GALLOWS
MODEL NUMBER: /Y 9? D---ZA INC14ES OR 7-5-0 GALLOWS
SWITCH TYPE: M~Egmel2 F/ MOTE: PUMP AMD ALARM ARE TO BE
MINIMUM DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET
+ M~~IAJ~IIMUM NETWORK SUPPLY PRESSURE . . . . . . . _ 2.5 FEET
+ - &A FEET OF FORCE MAIN X _AAz/
goo FxFRICTION FACTOR..- FEET
TOTAL DYNAMIC HEAD = IVA FEET
INTERNAL DIMENSION!: OF TAWK: LEAIGTH__;WIDTH --Z2.1 ;LIQUID DEPTH
I SIGIJED:
LICEMSE HUMBER'. 320 DATE:` ~-~L