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O. 0 O. c c C C C C O. d O 0 o. cl I°- ;Ei V a w •p" ~ c c o > > c I- I- H H F- a d a a a n iR g H g m c c c c c c 0 N ~ • ~i u m o o o c (9 3 E U) w v°i u°i 0 ai a) 0 0 a) 0 0 Q 4 4 m o o U .2 r- E m o c'a o o o 0 0 0 0 0 0 o m F- (U w I- C7 H Z h z 2 z M X M F- U) U) co m in U) H 11 0 A -r Wisconsin Department of Industry, County: Labor and Human Relations PRIVATE SEWAGE SYSTEM , Safety and Buildings Division INSPECTION REPORT St. Croix NW4,NEi,Sec.31 (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION T31N-R18W Co. C 149147 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: Charles & Blanche Bjorklund Star Prairie CST M Description: Parcel Tax No.: 516D - 038112560 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark Septic Dosing Aeration Bldg. S wer Holding / ' nlet TANK SETBACK INFORMATION St/ Ht Ou et TANKTO P/ L WELL BLDG. r tta a AD nlet Septic A t Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM I Loss Friction System TDH Ft TDH Lift mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER model Number: System: 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.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION MLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY s r c ; x STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 i o to previous application nches in size. ch I'lU -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER t( t PROPERTY LOCATION C r ~S `2vfAw. 1-i &7- ~u lV 1A1 % A/ = S T N, R S E (or& PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # M CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1,1114 11. TYPE OF BUILDING: (Check one CITY r~ NEAREST ROAD ❑ State owned VILLAGE rrc~i F-i~ Co. OWN OF. ❑ Public 1 or 2 Fam. Dwelling-# of bedrooS P R EL TAX UMBER( ) - Q 3 8 S G III. BUILDING USE: (If building type is public, check all that apply) 5-goo 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. ❑ Replacement 3. ❑ Replacement of 4. 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-Pres ized 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 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. 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 (s ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATIOJV L4 ~ 01 a T 1; 10 on, I, k Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank ©b C i Lift Pump Tank/Si hon Chamber 0 P t VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: D o m 14 9 s oh b er 7 3 .2- 3 Plum er's Address (Street, City, State, Zip Code). 7T t 4- P 9 I.4 1.11 v/l v f 7 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater nteissued issuing Agent Signature No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial 147t-> Adverse Determination Ald I rff- P a11&4_4J _'11/ 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 INSTRUCTIONS 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 permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 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 8 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be; installed. Il. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family 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 gallons, 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 to 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; friction 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) DEPARTMENT'OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, 1 c DIVISION LABOR As.D PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN 13ELATIONS (IL 3.09(1) & Chapter 145) XLOCATIO SE TION: SH UNIC LIOT NO.: BLK. NO.: SUBDIVISION NAME: 4 N/R/ (or T : OWNER'S/BUYER'S NAME: MAILING ADDRESS: ~2 _ell ell t USE DATES OBSERVATIONS MADE NO. B DRMS.: COMMERCIAL DESCRIPTION: R NS: ERCOLATIO [TRe,-,dence ;;2- ❑New Replace TESTS: I / ~d t O" E'j T D~ O RATING: S- Site suitable for system U- Site unsuitable for system ONVENT NAL: MOUND: IN-GROUND-PRESSURE: IS STE - -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) sou sou s []S ❑s If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: r Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 0-71,,Y/A 5/7r-/o►',8.~ .S//~-~F~~,~ Sy~^ c~--7 s/"7-i is - &-a B- - .f- 01 B- s3 t O $.~%L~i, S% 5r- / lV9 r /a -SE> - Zsi_L X14, 7- GY?~ G B G O- 7,$1 en 7,/oZ,~i~ 0'04 S B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER IsiSOM AFTERSWELLING INTERVAL-MIN. D PE D PER INCH P. / c o? P- 44, A0A0, A- s- a P- /L t P- P- ' P- I 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. i SYSTEM ELEVATION 12. S ee, r c- i i r 0 zxi S 7- f O;;~w G + ate- _ o~Y a 5 . !I f UIN r 1 I, t e 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 Wisc nsin Administrative Code, and that the date recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (pri t : TESTS WERE COMPLETED ON: ADD CERTIFICATION NUMB R: PHONE NUMBER (optional): t ;k- 4-CST SIGN TURE. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - I zs 1~ M• ~ 8- z ~~"`t i3 - I I t9 chi Sow ~ Iv~~'" 3='xSN 0~._ ` Ica Pa'4 22. / 2_,. lg71 co Rel sarrrc ~ sit W,' Sys -W G I. - X17, ~ S , ToP Corsair F!. 3 Sccr, I ~ Form- S T C - 104 • AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T tLN-R~-,"-W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT ✓ LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM fro r b S s~ cab~,~ W yy INDICATE NORTH ARROW uLr- BENCHMARK: Describe the vertical reference point usedl'ae e-6A e r-n erQ Elevation of vertical reference point: ^T OQ Proposed slope at site: _ SEPTIC TANK: Manufacturer: 1-1„9 e e k Liquid Capacity: lot r7ce4h~ Number of rings used: © Tank manhole cover elevation: l Tank Inlet Elevation: Tank Outlet Elevation: Ile Number of feet from nearest Road.: Front,O Side, Rear, ~feet .From nearest property line Front,0 Side,O Rear, O feet Number of feet from: well Le , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE a PUMP CHAMBER Manufacturer: _ t e e Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Z Pump Size Elevation of inlet:--9 Bottom of tank elevation: 'W 'bb/ Pump off switch elevation: Gallons per cycle: Q9 Alarm Manufacturer: (112;W JCAlarm Switch Type: c-5rL1,~ ~fGT~ Number of feet from nearest property line: Front, O Side, Rear,0 Ft. Number of feet from well:_ Number of feet from building g (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines: / Area Built: Fill depth-to top of pipe: ~l( Number of feet from nearest property line: Front, O Side, 0 Rear, 0 Pt Number of feet from well: Number of feet from building: 74/ (Include distances on plot plan). 1 r SEEPAGE PIT Size: Number of pits: Diameter: Liquid dYopbox Bottom of seepage pit elevation: Area BuiHas either a O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK I Manufacturer: Capacity: I Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, ~Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT Or INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR&KUMAN RELATIONS _ PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969, r BUREAU OF PLUMBING s MADISON, WI 53707 - CONVENTIONAL ❑ALTERNATIVE sate Plan LD. Number 111 -,q,,edl El Holding Tank El In-Ground Pressure El Mound NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER. INSPECTIO ' Chuck Bjorklund Rt. 1 Box 163, Somerset WI 54025 - to / BENCH MARK (Permanent reference point DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST HEF. PT. ELEV NW NE, Section 31, T31N-R18W, Town of Star Prairie Name of Plumber. JMPIMPRSW No.. County S--,y Pe.-I Numben Byron Bird, Jr. 3318 St. Croix 8379-1 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV TANK OUTLET ELEV WARNIDNEGDLABEL LOCKING COVER G PRrrO~~VlI PROVIDED o (D o C~ / - 7J, AYES ❑NO ❑YES -'*0 BEDDING. VENT DIA. VENT MATL. HIGH WATER NUMBER OF ROAD: / PROPERTY WELL BUILDING. )VENT TO FRESH v .Z AIR 1=LET ALARM FEET FROM . LINE ❑YES O ❑YES i3NO NEAREST , DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL jPLJMP,SIPHON MANUf Af TUREH WARNING LABEL LOCKING COVER ~j P OV DED PROVIDED b❑YES NO~~ YES ❑NO YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WFLt. BDILDIN(VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR PUMP ON AND OFF) YES ❑NO NEAREST-~ 7 SOIL ABSORPTION SYSTEM. Check the soil moisture at the de th of Plow in LFNGTH IIIIA111 TF 1+ MATT RIAI AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF JIIISTR PIPE SPACING COVER INSIDE DIA .PITS LIQUID BED/TRENCH THENt;y MA UALPIT CEPTH DIMENSIONS f- GFtAVFL DEPTH FILL DEPTH DISTH PIPE DISTH. PIPE DISTR PIPE, MATERIAL NO. DI NUMBER OF PROPERTY WELL BUILDING VENT TO FHF SH 1Bf LOW PIPES ABOVE COVER f 1 FV NI F T E V N FEET LINE AIR INLE T X72 EET FROM /•J NEAREST-----p- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MAHKFHS (MSI HVnII()N WI I I S ❑YES ❑NO _ _DYES _ ❑NO DEPTH OVER TRENCH BED DEPTH OVEH TRENCH BED DEPTH OF TOPSOIL SOUDF I) SEEDED Ml1 LCllf U CENTER EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATERAL SPACIN(, (;HAVEL UE P711 BELOW PIPE FILL UFPTH ABOVE COVEH BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR- PIPE MANIF OLD MATERIAL NO DISTH DISTR PIPE I)I 11 B(11 ION PIPE MATT HIAI & Nl AtTINI, ELEVATION AND ELEV. ELEV. CIA ELEV. J ]PIPES UTA DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHRECT I_Y COVER MATERIAL VEHTICAL LIFT CORRESPONDS TO APP14OVI U PLANS ❑YES ONO ❑YES ❑NO COMMENT PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL'. BUILDING. - YES NO FEET FROM LINE - - - ❑ ❑ ❑YES ❑ NO NEAREST A, , Sketch System on Bet inounfy file for audit. S Reverse Side. SIGN TITLE DILHR SBD 6710 (R.01/82) r,„ 7InD CDnsin APPLICATION FOR SANITARY PERMIT t DILHR ~f Gr°,h COUNTY (PLB 67) UNIFORM SANITARY PERMIT # STRV, , LABOR 6 MUTFn RElfiTlonS U -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS &Or PLOCATION CIT : 1/4 1/4, S T , N, E (or VILLAGE: yd~~ f LOT NUM E BLOCK NUMBE SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED y~ 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair i Replacement Soil Absorption System ❑ Revision ❑ Privy Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. AtSeepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: C e IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): X Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur . MP/MPRSW No.: Phone Number: r s Address: Name of Designer: G G zz, COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved p~ ❑ Owner Given Initial 7 0 Approved Adverse Determination Reason for ap val: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. INDUS T MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ~4VDU$TRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUlUTAN FIELATIONS MADISON, WI 53707 3707 (IL 3.09(1) & Chapter 145) LOCATION: SECTION: OWNSH U N I C,14A L I TY: LOT NO.:BLI, NO.: SUBDIVISION NAME: 1 42:2 1/4 1/ /T3 N/R/ (or 61 r © o OUNT OW ER'S/B YER'S NAME: MAILING ADDRESS: USE ~Cor DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS: Residence ✓7 ❑ New Replace / / 4- RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LLHOLDING TANK: RECOMMENDED SYSTEM: (optional) MS DU S ❑U S NU I ❑S [YU OS If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: r Floodplain, indicate Floodplain elevation: 1015; PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST, HIGHEST— TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B-- - - ' ZiPL B-Wy9A 0` 7 i8/' ~n •s~ 7-,/02 B- B- -ec f- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I46Mt AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P RIOD PER INCH P- / C y 19 o? P- -.5-- d P- .z~ 3 o'Z 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 Yr o E 3 f f'Df oCorr - I O°Y o, 7P S/ A-W X_ v 3 E , , I, t e 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 Wisc nsin 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: 41 07~'O'a _r ADD CERTIFICATION NUMBER: PHONE NUMBER (optional): CST IGN E: r DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - IN-Tr ION. `°f LETING 1 116 - S6 - 6396 Tu, e yo at- re} ors nirisl plc r ' a r c;otrtnie€"cial Project; y j31a'E [ cSITA' A HOLDING TANK ONLY ?F ALL i ~wD ON SOH {DNS; r v ...":-,:a tptions and completing the plot plan; _ gr,: ra -~c inn your t: cations Drawing to scale is preferred. A { be used if desi~ . S. Mz, sure your sn€;hrnark and vertical elevation, r c ° point are ar r' m<< lent; 9. Complete all c mate lac~xes ; ~"s slates, narrt it suxs, flr exetnp Lion, if apt-c_ id. If the informa in touch as fit evatiat-0 does not apply, iaiace N.A. in the appropriate box; 1 . Sign the form and place your curri your certification n: 12. Make legible copies and distribute i t 1. ALL. SOIL TI Slo , ."S~ BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYL JF.- -IMPLETION. e~ VIATIO1 ; t CERTIFIED SOIL TES, tS Sol' s artd Textures {ether Symbols st BFI Bedrock cob Coles SS - Sandstone sf= C 3") LS Limestone s and HGVV High Cxroundvwater cs Coarse Sand Perc Percolation Rate need s - 1%,1eclium Sand W Well fs Fine Sand Bldg Building is - Loarny Sand > Greater Than °'sl Sandy loam < - Less Ti-Ian im Bra Brown Lo. r BI Black Gy Cray Y Yellow f Loam R - Red `._oam mot OS Sa y vv/ - i fff f v, fine, faint Clay cc; conamOn, coarse tat - P, .:t nim - Many, medium rn d distinct p prominent HWL - High water level, Six (jone.ral it textures surface water for lids i isposal M Bench Mark VRP Vertical Reference Point TO THE MINER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. 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 1~k,3 e ,L Location of Property,', Section 3 / , T 3% N-RW Township 5~ Mailing Address Fox 163 c eC C't 5 e z S` Address of Site I i Subdivision Name Lot Number Previous Owner of Property e,•;h~ ,y, ~pC>-e-t /rte ~r~•~-c~« Total Size of Parcel J-4s~L eS ~Cre Date Parcel was Created C Y~6 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume 3? 7 , and Page Number / p 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) eehtiby that att Statements on this bokm cute true to the best ob my (om) knowledge; that i` (we) ms-(cute) the ownen(a) ob the pnopWy deselu.bed in th.i,a .inbohmation Bohm, by viktue ob a waAAanty deed neconded in the Obb.ice ob the County RegisteA o4 Deus o Document No. z. E, 5~ 2 e~ ; and that* (We) phesent.2y own the phopobed atite ban the sewage di~spod bystem (on-*-~ have obtained an easement, to nun with the above de c ibed phopehty, bon the con6thucti.on ob chid ayatem, and the tame ha.6 been duty neconded in the Obb.ice ob the County Reg-i.bten ob Deeds, " Document No. i SIGNATURE OVOWNE SIGNATURE OF CO-OWNER ( APPLICABLE) 7 - DATE SIGNED," DATE SIGNED No, 2110. 111 tsLt? Derd -'l Hu ! 1uk1 '111Q Wife el Jo t i 11 Published by Eau Clain Beak l B'.atlan.ry Cis, I) iz Inbenture, Made this 9th day of February , i9 61 , between Urban Germain & Pauline Germain, husband and wife, and each in thelt own individual capacity y_ - _ r- part ies of fhe first part, and Charles B orklund and Blanche Etorklund, - • i husband and wife, as joint tenants, parties of the second part. Mitntoortb, That the said part 1es of the first part, for an, in consideration of the sum of One thousand (S1000.00) - - - - Dollars, s ♦ ~ t. tisL...lt' tdli, :!{4L.' LLjll%.'+.i■ UY(1 pUl O2 i'! to "them' x`•11 ~"h nfl;Void ~ ~~tlie*s' fd"pa~`treswf' the second part, the receipt-iihereo"f is 'hereby confessed and acknowledged, ha ve given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate situated tin the County of St. Croix . Wisconsin, to-wit: The point of beginning is a point on the Easterly line of County Highway "C" 373.06 feet Yorth and 144.3 feet East of the Southwest Corner of said Northwest quarter of the Northeast quarter (NW1NED Section Thirty-one (31), Township Thirty-one (31) North, Range Eighteen (18) West; Theme East and parallel to the SoutUi-N&lfi) ine of said Northwest nuarter of the Northeast quarter Section Thirty-one (31) for 226.55 feet';', "Thence •Norith'17056'''„E6st for 100 feet;' Thenoe'kWest and parallel to the said South line of Northwest ouarter,of the Northeast uarter (NW4NE4) of Section Thirty-one (31)_for- 22.0.K_ feet to' its inter- section with said Easterly line of :County Highway "C"; Thence Southerly aloha said Easterly line of County Highway "C"; for 101.71 feet to the point of beginning. A.419o..vL11tithat'.str-lp-~.of=;-lacnd 1yi-ng -'between the Easterly line `.1.. of ;the ,above d~escr4;bed..tract and the Westerly shoreline of Apple River and between the North and South lines of said tra'dt'-each`eXten(Ied-Ea*!~terly t'c'the -Westerly shoreline of Apple River. 1 .A, Zoget4tt, with all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part i es of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. Co babt BAD to 4j01b, the said premises as above described with the hereditaments and appurtenances, "unto the said parties of the second part, as joint tenants. RM6 tbt $aib, Urban' Germain and `Pauline Germain part ies of the first part, for themselves, their heirs, executors and administrators, do covenant, grant, bargain and agree to and with the said parties of the second part, and to and with the survivor of them, his or her heirs and assigns, that at the time of the ensealing and delivery of these presents they are wet] seized of the premises above described, ! soot 377 • ao~f :3 f ~ ~ l.st1 ds of good, sure, perfect absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever. and that the above bargained premises, in the quiet and peaceable possession of the said parties of the second part, as joint tenants, a :^sr all and every person or persons lawfully claiming the whole or any part thereof they will fflrer WARRANT AND DEFEND, In Witntoo MOrrtot, the said parties of the first ha Vehereunto set their hands and seal s this day of Februaryy , 19 E1. • (Seal) Signed, Sealed and Delivered in Presence of 1 P9111 inn Gprmain Joseph W. Hu it e s - Frances Van NAVe1 %tatt of Wi0conoin, ss. St . Croix County.))) On this the day of February '19 , before me, Joseph W. Hughes , the undersigned officer, personally appeared Urban Germain and Pauline Germain , known (or satisfactorily proven) to be the persons whose names subscribed to the within ins, rument and acknowledged that biey executed the same for the purposes therein contained. In wilts m whereof I hereunto set my hand and official seal. Joseph W. Hu h s Notary Public, St. Cro Ix County, Wis.c9p#n. My Commission expires June 9 19 b~. (To be !filed in if sl¢ned by a Notary publlc.).,7:•(li 1 t ^ 1!f.H..--CA. 59 Wla, ltata. srovill that all Instruments to be reeorded obau have plainty orletl or typewritten thereon the name, of the trantors. aTasteea, -!menses ass --tars.) s r-{ o b v oli, C\, 'u ` i 1v co i. II i GL 'L7 E fx+ i O o v l a°ii I I ~i iii ro• ~ U r~ V a. c - \ ~ - Ut ~ ' I ~ _ ( I C4 I o co PQ p H N H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z cy a H OWNER/B eares ~u ROUTE NUMBER R7" % '&4,5c 16,3 Fire Number 5'301? .CITY/STATE Si~wL~,-,s 7L ~~S ZIP Sytp,Z'J' PROPERTY LOCATION: A)kA, /U C k, Section 31 T 31 N, R W, Town of 54~n 2y)dii-re- St. Croix County, Subdivision Lot number 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 pelt 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. H 0 E _W/WE, the undersigned, have read the above requirements and agree vi to maintain the private sewage disposal system in accordance with x 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 Office within 30 days of the three year expiration date. SIGNED DATE 7`- St. Croix County Zoning Office / P.O. Box 98' Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. c ~ r x ~ x d o ~ N'~~~ w?ccN30 N ~ma° ~mnnm~__ on. o C: fn w =r z 3 c (o n I '.:z o °~f (D •0 m m p? H r 0 C (D lp m~ ~ N~ yyr ° a 0 n xo (D (D C (D m 0 m w oo _ .0 r (p • ? m -w ? (D A ~3a 0a°CD CD Co co W = o ° o c 0c3o a 0 n wws c~Q- +0 0 w ~ CD m ~ 0 ~o am ° ° m w ~mc~ U) C) m (n U) o D gm C) c o 0 = w n CD 0 ° C-- ° m CL 0 0 CD U) ai m y U) w iD Z ~ m m N' =r ID Z m a m° m 3 (AD (D 1 m as ?°:?C w o M Qu' a m 0 w an p ~aU) :E CD C m m 3 m 0 ~ vm=-0)=-' mcE• 0a m =r 37 ~mm co m-1 Wv n CD wO~Qw_ _ w 7 m "C n N N CL o F 0) c CC caw o9~ G) ' 171 r~~Ik c (D w 7 w a n a m w m m a - a o. U1 Q ? N c: G) co =r (D mac _ a ~0 70m0 ~22, a 0 On c" " (A - ~ _a caw (D (D D s _3 0a n p; ~~3 0j o'o° ~m 'a w¢_0 am °o3 3 (D vi o. o < r o m z 0 PROJECT f a,,ADDRESS ~D~! el Sam/ x + Mdl/4 ~1/4/S~/T3/N W TOWNf OUNTY BEDROOMS CLASS PERC CONVENTIONAL_ CONVENTIONAL LIFT MOUND_ HOLDING TANK- IN-GROUND PRESSURE_ SEPTIC TANK SIZE 0 I IFT TANK SIZE d DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION =A P RC RATE BED SIZE PLUMBER v LISCENSE NO..3 r DATE BM Xssume eleva 'on 100' Location of Benchmarks' Q Borehole Q Well v 0 Perc Hole System Elevations' TYPAR COVERING ('f) CV I 12 2" 2" 2 Kft. g" Sewer Rock i 12 ft. 18 ft. 2 en"11 C_ i r J ro Sa~kTc v 65 a Gejoj 1 17 PAGE PUMP CHAMBER CROSS SECTION ARID SPECI ICATIOWS YEfJT CAP "C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING ;5' FROM DOOR, JUNCTION BOX MANHOLE COVER 'INDOW OR FRESH IZ"MiLl. IR INTAKE GRADE 4" MIN. 'lag 4/1 I COIJDUIT - - - - - - 16"MIN. 11~ INLET PR014t1 I - AIRTIGHT SEAL I I I I ~ PPROVED JOINT A 1-77 I I APPROVED JOINT ''/C.I. PIPE III W/C.I. PIPE CTENDIIJG 3' I II EXTENDIAIG 3' ALARM M SOLID SOIL 6 I ( ONTO SOLID SOtL .EV.,_. FT. PUMP ter„ OFF D COUCRETE BLOCK' RISER EXIT PERMPITED GWLy IF TAIJK MANUFACTURER HAS SUCH APPROV L SEPTIC e SPECIFICATIONS U DOSE TAWKS MAMUFACTURER: - NUMBER OF DOSES: PER DAB TAWK SIZE: :6C 0 • 2 GALLOIJ5 DOSE VOLUME ALARM MAIJLIFACTURER: w.v INCLUDIMG, BACKFLOW: GALLONS ,cdr r. MODEL, 11UM8ER: CAPACITIES: A= WCAES OR GALLOWS SWITCH TSPE: - ,e~" {~t t B= _INCHES OR Q GALLONS` PUMP MAMUFACTURKIt:._.,',;,,~~~ INGHE5 OR GALLOWS MODEL MUtA5ER: D~ - 1MCHESO'It 49 192 GALLOIti1S SWITCH TaPEi r~ (t NO E' PUMP A►Jt3 ALARM ARE TO BE MINIMUM DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEM PUMP OFF ANO 018TRIBUTI0N PIPE., FEET + MI#JIMLIM NETWORK SIIPPL~j PRESSURE ,r,r►, . , FEET + /FEET OF FORCE MAIN X Froot<tFRICTIOU FACTOR.. 60 FEET TOTAL 01, IWAMIC HEAD Zl' FEET • MTERNAL DIMEAISIOMS OF TAUK: LERIC,TH ;WIDTH , /;LIQUID DEPTH _