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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Lot 16 County:
Labor a nnHumanRelations
Safety and Buildings Division INSPECTION REPORT Northern Oaks St. Croix
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION Sw,NW4,Sec. 15,T31-R19,Martell Dr. 149205
4
Permit Holder's Name: J ❑ City ❑ Village Town of: State Plan ID No.:
Laura Walsh Somerset
CST BM Elev.: Insp. BM Elev.: BM escription: Parcel Tax No.:
I D-0 - 0 1 dw/,4,7x_~ 49461& - 1 -1
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
S Q~
Septic Benchmark 15 10~,1
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet h.75 aS y
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/Man. 75
Aeration NA Dist. Pipe l~ 7 a3
Holding Bot. System g~ ~3
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~I DIMEN I N
LEACHING Manu acturer:
SYSTEM TO P / L BLDG WELL LAKE /STREAM
SETBACK
INFORMATION Type O CHAMBER Mode Number:
System: /6~~ OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. 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
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
1 1 I # ' ~i
Plan revision required? ❑ Yes ~o
Use other side for additional information.
SBD-6710 (R 05/91) Date I pector's Signature Cert. No.
C9 0/
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER cs ion a u~ TOWNSHIP
S ECT I ON~, f_T-?I_N-R~q,-W
ADDRESS ST. CROIX COUNTY, WISCONSIN
'S"z 14L
SUBDIVISION LOT_2_LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTY ARROW
BENCHMARK: Elevation and description:
_,b~
Alternate benchmark
SEPTIC TANK: Manufacturer: - Liquid Cap. 1
Rings used: Manhole cover elev: ,9f//Final grade elev: 97',7."
Tank inlet elev.: 9s-Z~ Tank outlet elev.: 9
No. of feet from nearest road:Front , Side , Rear-2LFt.'
From nearest prop. line:Front , Side, Rear Ft.
No. of feet from: Well , Building:_ Al
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
• ~ 1
x
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 5-2 Number of Lines: -,'2 Area Built
Exist. Grade Elev. ~ S-~ Proposed Final Grade Elev.
s
Fill depth to top of pipe:
i
No. feet from nearest prop. line:Front , Side , Rear-.LFt."
No. feet from well:^
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: , '14 LZ)&
I
LICENSE NUMBER: ~ 9
v
6/90:cj
9:1 SANITARY PERMIT APPLICATION
EZIn 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 le-10-7(9 9-
8% x 11 inches in size. 1:1 ec if re6 on to 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
S JS- T , N, R E (or)o
PROP TY OWNER'S MAILING ADDRESS LOT # BLOCK #
, ~2 . /(I I
CITY, STATE ZIP COPE PHONE NUMBER SUBDIVI ON NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) State Owned ❑ VILLAGE 1111
❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms PAR ELTAX NUMBER(b)
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 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. LrnUjl New 2. ❑ 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 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 220 In-Ground 420 Pit Privy
130 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
3 Feet 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
_W_ -17- Li I
Septic Tank or Hold in Tank E] El I El El I El 1 0
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installatio f the onsite sewage system shown on the attached plans.
Plumber' Name (Print): Plumber's gna re: No Stamp MP/MPRSW No.: Business Phone Number:
I
Plumbs 's Address (Street, City, State, Zip Code):
IX. C NTY/D PARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date IsAued Issuing Agent Signature (No Stamps
Approved ❑ Owner Given Initial J) 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
S T C - 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
Location of property,
Sh2l/4 L 1/4, section , T_LN-R1l_W
Township
Mailing address
1
Address of site S
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? - Yes No
Is this property being developed for (spec house)? Yes _No
VolumeQand Page Number X30 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 the office of the County Register of
Deeds as Document No. 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.
Signature of a licant P~ Co-applicant
Date of Signature Date of Signature
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER v~ A4'z~z
ADDRESS: FIRE NO:
LOCATION : 1/4, 1/4, SEC. T_=ZLN-R_L W,
TOWN OF: - ST. CROIX COUNTY
SUBDIVISION: - LOT NO. ,L/^
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:
L.
DATE:
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND P.O. BOX 7969
PERCOLATION TESTS (115) MADISON W153707
HUMAN RELATIONS
OLHR 83.09(1) & Chapter 145)
OCATION: SECTION: TOWNSH MUNICIPALITY: ~OT NO.: LK NO.: SUBDIVISION AME:
1/ /4 /T N/ E (o anR r r /~5
COUNT IMAILING ADD SS:
I -R
S DATES OBSERVATIONS MAC /T O/
NO. B ION: New TESTS:
DESCRIPTIONS: PERCOLATION (Residence ❑Replace r e~
RATING: S- Site suitable for system U- Site unsuitable for system
ONVEN NAL: MOU D: IN-G N : S YSTEM-IN-Fl LL 0 DIN TANK: RECOMMENDED SYSTEM:(optional
= 112% sou
~Zm ou Ls []U o s u EIS Ou
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.0915)Ib), indicate: Floodplain, indicate Floodplain elevation: a
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER•INCHES HA RA TER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED I TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- f .6 0 b "'g /a/
B-~
AX0
.a
B-3 4-a o-'e-
BT
B-
1) PERCOLATION TESTS
TEST DEPTH • WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUM ER AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D PER INCH
P- I e- Z- G
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
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1, 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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SI A RE:
r
61STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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