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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER d^ F,4ell'e 1,L TOWNSHIP
SECTION TaE_N-R2W
ADDRESS CTS' M ST. CROIX COUNTY, WISCONSIN
onr r,-a//5 Ly
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
-ef
m ~ ~ ova
. v I
®100,0 ~ ~ ~ o Pr~~as
boy, /p0.6
J
I~
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: llma S fox-
Alternate benchmark
SEPTIC TANK: Manuf acturer :x es ~`i y
Gf.6 yl Liquid Cap. d'o
Rings used: Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side , Rear Ft.
From nearest prop. line:Front , Side , Rear Ft.
i
No. of fast from: Well 0 , Building: 1'5
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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 05
I,
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width:-L~-Length Number of Lines:_j _Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Jr
Fill depth to top of pipe:
No. feet from nearest prop. line:Front/r , Side Rear Ft.---~' cPDD
No. feet from well: 70(4 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:
LICENSE NUMBER:
6/90:cj
qt o6a -
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT St. Croix
SafPtyarid Ouildings Division
S(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION SE4, -SW' , ec.33,T28-R19, o. Rd. M 149192
Permit Holder's Name: ❑ City ❑ Village [4:Tovvn of: State Plan ID No.:
Grecar Koehl S91-40356
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
)d?JiG~ 526B 04011 2640000
TANK INFORMATION ELEVATION DATA
cC 4.6.-
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 03
Dosing 3 97/ Gv, G(i
Bldg. Sewer
Holding St/Ht Inlet CD
TANK SETBACK INFORMATION St/ Ht Outlet>
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing ~z! >~s~ NA 4 eade / Man.
NA Dist. Pipe j 3,17
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 0,- ie Q d /0y0-5~' 1.30 S'
Model Number ~d5 GPM
TDH Lift' Lriction~System TDH~,(,5F t ead 21q)
Forcemain LengthI Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length 1 No. Of Trenches PI Of Pits Inside Dia. Liquid Depth
DIMENSIONS I S DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Ma urer:
SETBACK
INFORMATION Type Of ' Mo a Num er.
System: n'l~ >ZG~ .W~~ CHAMBER /4 OR UNIT
DISTRIBUTION SYSTEM
~+etrd~r/ a ifold ,i Distribution Pipe(s) x Hole Size ~i x Hole Spacing Vent To Air Intake
Length Dia. LengthZ Dia. Spacing q$//
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over „ Depth Over xx Depth Of xx SeededLSedded xx Mulc ed
Bed /Trench Center Bed /Trench Edges 12' - Topsoil (y ` es El No es El No
COMMENTS: (Include code discrepancies, persons present, etc.)
L~- C,tti-1GA.{ &
Z 4 C r t L C' ? ce
'I Zl
JA
Plan revision required? ❑ Yes ❑1Vo
Use other side for additional information. C)
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
[~70R.HR SANITARY PERMIT APPLICATION COUN
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMI #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 9/ 9
8% x 11 inches in size. check revision to prey s application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S s-
PROPS OWNER I PROPERTY LOCATION p,
d '/a 4J S To7 0 , N, R E (or
PROP OW ELING ADDRESS LOT # BLOCK #
3 FOM7 4~r
CI, STATE ZIP CODE PHONE NUM SUBDIVISION NAME OR CSM NUMBER
t! f~' < w
s2
11. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
( ❑ State Owned c~ VILLAGE
❑ Public V1 1 or 2 Fam. Dwelling-# of bedrooms PARCEL A N UMB ( )
III. BUILDING USE: (If building type is public, check all that apply) ^ ^ 11A 119060 K Ll
1 El Apt/Condo Z'L.' 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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) 1.0 New 2. R [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-Pressurized 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 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
71-)0 1 A (d1 10-° 75' Feet .~Gf Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 060 1,14 d TA
Lift Pump Tank/Si hon Chamber V
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for install tion of the onsite sewage system shown on the attached plans.
Plumbe s Name (Print): Plum gnature: (No S ps) MP/MPRSW N Business Phone Number:
C x a ~ /ax(?
/S ;--7- a , 4A 1 9 ~
PI m r s ddress (Street, City, State, Zi Code):
IX. COUNTY/DEPARTMENT USE ONLY
F-I Disapproved S nftary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signatur Stamps)
Approved ❑ Owner Given Initial ~ Surcharge Fee)
Adverse Determination 4/6 a 19 0
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
• 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 G
Location of property JC 1/~ ) 1/4, Section -?3 , T d oN-R V
Township P0
7----
Jpc 75
Mailing address
Pt 10 Ll~ ~L
Address of site 15glt r
Subdivision name
Lot number
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? --~L_Yes No
Is this property being developed for resale (spec house)? as N0
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and
the ORAL 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 dea dad in the Office of
the County Register of Deeds as Document No. `?P
, ,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 du y e orded in the Office
of %ve Coin later of Deeds, as Document No.
Signs re o Owner Signature of Co-Owner (If Applicable)
D e of ignature Date of Signature
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
Q
ROUTE/BOX NUMBER FIRE NO.
2t
R
Y/STATE t''L)f ZIP 0~
CIT ~
PROPERTY LOCATION: J 1/9 S 1/4, Section , T_2& Rte--W'
Town of ~G' St. Croix County,
Lot No.
Subdivision
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 July 1, 197. rCroix
1980, with the requiqui
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
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED
DATE
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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUASTRY, c DIVISION
LABR A~ P.O. BOX 76
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
S E W0114 T~ ~-N/R/ E (o W giro
COUNTY: NE BUYER'S N ME: MAILI G ADDRESS:
e o' rje lei ga 55 P('Utz F 4,11y USE DATES OBSERVATIONS MADE
NO. BEDRMS : COMMERCIAL DESCRIPTION: PROFIL DE IPTIONS: R L I _ N ESTS:
Residence ❑ Neweplace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
[--Is ®u EIS ou as 'Hu ❑S ZO oS ,®u AA
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGH_EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- . a ; oD, fig'` 9' s d /f 't b Q0 cue s.' a,D ~8~ s F'
B- C~ 6~n C~~
B-
B- L"oh~ BBC e d CAD e /ho~s r,
cz'; 0/~ '3 t4 NA ea
B- 1~
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- y 0 1 1%4 5 r
P- 11 0 6 S'
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 _ /Op. 05
ca® ~~•Wl~ lDl~.~j ~r~ ~~~4~~ ~K, I c~stl to-he reaise
oot} + o e aise /I
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k k g
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 CO E E 0
a S ~ ~.n
ADDREW: CERTIFICATION N MBE : PHONE NUMBER (optional):
CST ATU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
V r~ KOCOCr-
~f
SOA Scc 33 Tl8 N R1~tJ
t`o}/ I Q~ns P
"rl4e E?ctS'T[N ~/l;•~KS Mv`S~ dL. lN~ i1zE ~F rn~U~FzEv 0
SG~'~-~viJCSS AWU i.CS AND 9-L- i'LG~1. ~i,r{fZ i6':W0,4,C- ~ `0XX4
~F NCcCtiSa~=`t ~J~• cR
of-
w
OP~AdOR AND 1 it)tvlA N REL.AT iOyu I SO, ~t-
E Y lIDINGS°~ 3 r 5 ~hc a ~w
3T 0,01
NISIOy p~Ct
i
R~K ~ EN~ ~ ~ 4. ~LLe 1
7 /
`n4G AREA 2-S Ff. tk~,L('W /
•I'N E t~. ~vNS~ ~pE uClE C r- Z i4 MSS
Mc~c.►c~ tvct:Sr c7.E.MAw u,it~iSTv~:~E.U
~ll
~ Tn~ Pfer,~t•
/ ~i5~ . U~J~
RECEIVED
JUN 17 199-
(A f) c LSAI-ILIT ULUGS. Ear;,.
~ 7 ~1
Page Of
Distribution Pipe Detail For Two Lateral Network
Holes Located On Bottom
Are Equally Spaced PVC Force Main End Cap 7
w
X X PVC Distribution Pipe
P P
X
* Last Hole Should Be Next To End Cap Y
P _ Ft. Pz 3bPt . Hole Diameter - Inch
X Inches Lateral Diameter Inch(es)
T
Y Inches Force Main Diameter Z Inches
# Of Holes/Pipe
Invert Elevation Of Laterals ld2 Ft.
i
Signed:
License Number:
r f1
Date: r J`
1YE SEWAGE SYSTEM
ON5
C • ' p.fLl
OV
S
pE~AP,Tf!! taT Of ►NOUVAY. YD D But JUIV 1
s► rr Of 199,
4
f
SEE C(1Ri~ES>-~E
g Of
Cross Section Of A Mound Using A Trench For The Absorptio ea
H 9-jMedium Sand Fill _ o F
._.I1 6" Topsoil
3 E D
ON 160V*GE S~ g'regate, Plowed Layer
w Pipe, C red With D Ft.
S w~,h► Synthetic Fabric
E Ft. G /.O Ft.
rtV PP-'v Dm- L; F 7~' Ft. H /-5- Ft.
'A K &,r-s
DEp,\jP, WENT OF IN9USTRY. LABOR AND HUMAN RLLA i 1ONS '
IVISION O SA Y 'D I GS
SEE CGRRE , KJE
Plan View Of ;found Using A Trench For The Absorption Area
Force Main
J Distribution Pipe REC ~E®
Permanent Markers Observation Pipe ,UN 17 199
W A o - AFEY`( QIDOS
B K
\
I Trench Of 2" - 2k" Aggregate
L L - ~1
A I = Ft. K Ft. W Ft. `4ECEJI _
B 7 5 Ft. J d Ft. L Ft. JUN 1 7 199,
I IIFfr License
Signed: ,.1
Number. Date:
r1
- PAGE OF
' PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
( ) VELIT CAP "
'i•C.I. VENT PIPC WEATHER PROOF APPROVED LOCK11►JG
JUIJCTIOM DOX MANHOLE COVER
~ 2S' FROM DOOR. IJ:•MIU.
t 'WINDOW OR FRESH
AIR INTAKE I
GRADE I H' MIW.
I ~ le•Mlu.
CONDUIT--
11
wfsu
1
ONSI?E SENIAC`E OVIDE ( I
. IIULET GHT SEAL
'jilt, LLLLLL~~[ I i I
,-a q
APPROVED JOINT rA jw& I I I APPROVED J(
W/C.I. PIPE IF NED r I I ( W/C.I. PIPE
EXTENDIM& 3' ;~"r ANA ~A~1 RELaT10~ 2~ i i i I ALARM ExTE1J01NG
ONTO SOLID SOIL rl ONTO SOLID
LABOR' I
CR;AFivt °IStoN ~f P+f I i Ou
. I
ELEV. SEE COHHES PUMP--,-~ --J
OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED OWL'S IF TANK MANUFACTURER HAS SUCH APPROVALT;,,...,,
~Dw
SEPTIC E SPECIFICATIOUS
DOSE
TANKS MANUFACTURER: i 0 IJUMBER OF DOSES: PER DAy
TAWK SIZE: 7 510 G LLOWS DOSE VOLUME 22&7L
ALARM MAIJUFACTUR.ER' INCLUDING BACKPLOW: GALL C
MODEL WUMBCK: CAPACITIES: A= INCHE5 OR GALLC
B = Z INCHES OR 3 GALLG
SWITCH TYPE: s
!!71
PUMP MANUFACTURCR: C =1 /-3 LINCHES OR z2G GALLC
c y'
MODEL IJUMBER: U ✓ D-~0 INCHES OR GALLG
SWITCH TYPE' /7/4 MOTE: PUMP. AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE ?Z GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFEREAICE BETWCEU PUMP OFF AND DISTRIBUTION PIPE.. ~I10 FEET RECEIVED
t MINIMUM WCTWORK SUPPLY PRESSURE . 2.5 FLET JUN ~ J 199
♦ Z 3S FEET OF FORCE MAIM X a J Fyo fT.FRICTIOU FACTOR.. ° ,07 FEET
..11r-L W uLJ{S~. ail 3 -
TOTAL OULIXMIC. HEAD = 2-15.57 FEET
LIQUIO DEPTH ..J~
WTERNAL. D M STOWS OF TAWK: LENGTH 6'7-;WIDTH
SIGNED:`T " LICENSE ►JUMBER: ~v 'J GATE ?
SAFETY & BUILDINGS
DEPARTMENT OF REPORT ON SOIL BORINGS AND DIVISION
INDUSTRY, DIVISION
HUMA
LABOR AND ' PERCOLATION TESTS (115) P SOX 7969
UMAN.,LAT`tONS MADISON, WI 53707
(1163.09(1) & Charier 145.045) ~LOCATION: SECTION: TOWNS~MUNICIPALITY: OT N0.:BLK. 0.: ION NRM
S C 1k 1/4 3a-/T) MR/~ E to W to Le- -
COUNTY: NE' BUYER'S N ME: MAILI GGl1DDRESS: ` Abell, DATES OBSERVATIONS MADE
- - -PRO -.-FI LE - DE--S-C- -I-PTIO ---N
NO..: C OMMERCIAL DESCRIPTION:
USE Residence El New &F BEDRMS RMS -S: PERI;~ - ESTS
leplace / L
,
RATING: S= Site suitable for system U- Site unsuitable for system
CONVENTIONAL: MOUND: JI~ffTANMENDED SYSTEM:(optional) S 2U E-1 21 S❑u oS Zu aZu S~
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is iunder s.H63.0915)(b), indicate: Floodplain indicate Floodplain elPROFILE
DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWA7EN-INCHFS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHI~N, ELEVATION OBSERVED ES III TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- } ✓ J DO, - 0 rl L1~ nJt IfIL' CD{ 1~11`~r S1 c~.J b/1 S~ 6v -
!r
IX-01-t-1 ad
B-
B- c1l')
C" i
Ted
e) o
B- a
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST IIMF DROP IN WA f EH LEVEL -INCHES HATE MINUTES
-
NUMbER INCHES AFTERSWELLING INTEHVAL-MIN. UC-1n - PFH INCH
I, L
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 boring; and the direction and percent
of land slope.
SYSTEM ELEVATION /d
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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 pr ced res and muthuds specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are corruct to the best of my knowle ge a d belief.
NAME (print) TESTS VV HE 0(v~F' E E O
ADD9ESrSf:~---~~~ CERTIFICATION N MBEf : PHONE NUMBGHIupuoiaull:
csi lac ATu IE:
DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Suil Tester.
DILHR•SBD-6395 (R. U2/82) - OVER -
( SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
PRIVATE SEWAGE PLAN APPROVAL Western Regional Office
2226 Rose Street 1gg1
LaCrosse, Wisconsin 5
~ S~ ~g04X
c' COIN
_ G OFF►CE c~
WANG EXCAVATING Owner: GREG KOEHLER ZONIN ~9 h
ROUTE 4 BOX 342 B ROUTE 3 BOX 557 5
RIVER FALLS WI 54022 RIVER FALLS WI 54022
RE: Plan Number: S91-40356 Date Approved: June 20, 1991
Gallons Per Day: 450 Date Received: May 21, 1991
Project Name: KOEHLER, GREG Location: SE,SW,33,28,19W
RESIDENCE
Town of TROY County: ST CROIX
The plumbing plans and specifications for this project have been reviewed for
compliance with applicable code requirements. This approval is based on Chapter
145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are
stamped 'conditionally approved'. This approval is contingent upon compliance with
any stipulations shown on the plans. All items that are noted must be corrected.
All permits required by the city, village, township or county shall be obtained
prior to construction. The licensed plumber responsible for this installation
shall keep one set of plans with the department's approval stamp at the
construction site. The installer shall notify the appropriate inspector when
inspections can be made.
This approval will expire two years from the date approved or if a sanitary
permit is obtained, it will expire the day the initial sanitary permit expires.
The Section of Private Sewage has reviewed these plans for private sewage system code
requirements only. These plans have not been reviewed for the code requirements
set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the
Wisconsin Administrative code.
This approval is for the following components only:
- REPLACEMENT PETITION
- REPLACEMENT MOUND
Inquiries concerning this approval may be made by calling (608) 785-9348.
- I
S1106423(H. OUB 11 -
i
1
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
WANG EXCAVATING
Page 2
Sincerely,
GERARD M. S
Section of Private Sewage
Division of Safety and Buildings
PPP039/0009n/20
cc: GREG KOEHLER X Private Sewage Consultant
a)
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SISD 61233 , N. u191 I
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
State of Wisconsin
Department of Industry, Labor and Human Relations
June 5, 1991
GREG KOEHLER
ROUTE 3 BOX 557
RIVER FALLS WI 54022
Plan I.D. No. 591-40356-P
Dear Mr. Koehler:
Re: Greg Koehler - Residence
Private Sewage System
SE,SW,33,28,19
Troy, St. Croix County, WI
Your petition for a variance to section ILHR 83.23 (1)(d), Wisconsin
Administrative Code, has been reviewed.
r
The rule being petitioned requires a mound system site to have a minimum of
24 inches of suitable natural soil.
The variance requested was to install a replacement mound system on a site
with 18 inches of sui tabl e " natural 'soil ,
Send plans for the proposed replacement mound system to the La Crosse Regional
office and use a long narrow trench configuration for this design.
The following comtn;ts were made in the petition analysis:
1. In reviewing the petition, it was noted that the request was similar to
other petitions accepted by this department under petition numbers
S89-03304, S89-03318, and S90-00072.
2. Based on the precedent established by the previous petitions, this
petition for variance is being processed as permitted by Wisconsin
Statute Section 101.02 (6)(g).
Departmental Action: Approval.
$R D'6928 (R. 0 I /91
ffi
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
State of Wisconsin
Department of Industry, Labor and Human Relations
Greg Koehler
Page 2
June 5, 1991
This approval is granted with the understanding that all of the petitioner's
statements and any conditions of approval cited above will be carried out.
Prepared By: Date :
, . . . _ .
en song -
Man Exams
P yq~ to
Departmental Signature Date:
Richar L. yer, rc ec
Director, Office of Division Codes and Application
DS:0693i i.
Enc.
cc: Leroy Jansky, Private Sewage Consultant - District 6, Chippewa Falls
Thomas Nelson, Zoning Administrator - St. Croix County
Tom Wang
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SRO 6828 iR.:01/6U -
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
- (715) 386-4680
April 29, 1991
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation of the Greg Koehler property, located at
the SE 1/4 of the SW 1/4 of Section 33, T28N-R19W, Town of Troy,
St. Croix County, revealed 18 inches of suitable soils requiring
18 inches of sand fill.
Should you have any questions, please feel free to contact this
office.
Since ely,
James K. ompson
Assist t Zoning
cj
AS BUILT SANITARY SYSTEM REPORT
PERTOWNSHIP SEC. 1-4 T62fr N. R~W
0. ADD?,ESS , ST. CROIX COUNTY, WISCONSIN.
.•3DIVISION , LOT LOT SIZE
PLAN VIEW
Distances b dimensions to meet requirements of H62.20
i
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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I dir-at4eozth xrow
SCAL I
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No-
-5177
PTIC TANK (S)MFGR. CONCRETE X STEEL
NO. of rings on covert ¢ v Depth DRY WELL ~Wmpw NO. of 3 width_ZjL_ length area 51j43
no. of lines width length area _
depth to top of pipe
' 6REGATE
,?.U RATE AREA REQUIRED 9~~ AREA AS BUILT g -:z -/ws, 11
tisciaimer: The inspection of this system by St. Croix County does not imply complete
o;pliance with State Administrative Codes. There are other areas that it is not possible
fo inspect at this point of construction. St. Croix County assumes no liability for
Istem operation. However, if failure is noted the County will make every effort to
Aermine cause of failure.
=EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
`,Z ECTOR
DATED w PLMIBER ON JOB
LICENSE NUMBER ~c~
Z
REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM
1
Sani.tany Penmix " _
• Saxe S P p.t.tcs~o ~
NAME (ah~p~ S Cno~x Cauny
T -
Locatiom Section
SEPTIC: TANK ~
Size /!y 1 gattonz. Numbers of Compantmentz
D.i..atance Fh.om: Wet 12% an greaten ztope-%~O-6t j
Bu.itd.ing~it. Wettands ~ •
j
H.ighwaten it.
DISPOSAL SYSTEM
Distance Ftcom: Wett 12% an greaten stope 6t.
Bu.itd.ing it. Wettand.6 Ft.
H.ighwaten it.
FIELD DIMENSIONS:
Width o5 trench l S it. Depth o6 %ock below tite% in.
Length of each tine it. Depth of rock oven Cite in.
Numbers of tines 3 Depth ob tite below gnade2 Vin.
Tatat tength o j ti n es./M 6 t. Stope o6 trench in pen 100 it.
Distance between Z ines-g~ t. Depth to b edna ck it.
Tota.C abaanbtion ate/JO jt2 Depth to gnoundwaten r it.
2 Requined area it Type o6 Coven: apen an Straw
PIT DIMENSIONS:
Numb en o i pits dovet around pitz yes no
Outside d.iamet fit.. Depth below inte it.
2
2
a 6 .can ea / '
Toxa.~ ab~s
A
2
Area ne u.ined it rm
INSPECTED BY TITLE
APPROVED , DATE 197.
_
REJECTED , DATE 197
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WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
A DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
\v
LOCATION: SW Section T , T~N, RL "W, Township o ipa y ti14J)
Lot No. , Block No. County S T• ` '
ubdivision Name
Owner's Name: G 0 iz--r leu(F-
12'i!L~ ~ ~4
4, 1Z ►j S~TZ- S ti 7r
Mailing Address:
TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACE
DATES OBSERVATIONS MADE: SOIL BORINGS s3 -I Z' 7g PERCOLATION TESTS s
et
R~v~ N
SOIL MAP SHEET P4 a tr 9 o SOIL TYPE Swow 9901 v'"' 1*0">, Do WoY
GnitiGL06 V-11cu 'T"r S►aaw'a
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- 36 Ste' ~vel,~k 1 z4 rbr~E 30 Z 5~~ ZQ~im Z"K. \1
P- Z 3( t►Z z¢ WoNrer 3a 3% 3 3~~ 3 3/ 9
P- 36 3 P& N C 3o 3 -Z % z ~ig l 0
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- ) 7 Z rJorrl* 7 7Z" Si TS is sic 17,. J-C4 1.-54 taNA 3-7 "
B - z ~Z Non+E > -'Z sd Ts 13 5~ c 1 11" w►~d s~Y•d `~-8"
41
B_ 3 -72 ►.10uCS 7 72" 13„ sic, 1 8" j w.ad sa.,d
8- d `72 NoNe 7 '7Z`• sit T dd c~r.c1 3Q
B- 5 '7Z Norli '7 SA TS 1 Z.. S,v~ 17 t~t~ Sa»al 4~3`
a- '7Z perJ6 77z~ :I T s,~1 Is r.,~~1 swNd 4s"
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and squar feet of suits le areas. Indicate number of square feet of ab~~~rption area
needed for building type and occupancy. Ad Y-AM&C At"' IDS 0~ p t Z X fl4s ~ Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) ..~ary~ yRpm Certification No. SS ' SZ~
Address /0O 3 y~ZEL ICytLS ~S .~_402.7-
installer if known
CST Signature
HORITY }
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State and County State Permit
PUB67 Permit Application County Pe it # tae
for Private Domestic Sewage Systems County, C f
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
CrEc~,vg y /~'eg,Ftf,L EJE. 'er 4 F1 V;im
r ,L L a, t~9~ ?z
B. LOCATION: tiUj %F Section ' TZ&N, Rl E~W W Lot# City_
Subdivision Name, nearest road, lake or landmark Blk# Village
Township T/P6y
C. TYPE OF OCCUPANCY: Commercial Industrial *Other (specify) *Variance
Single family kl"' Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES -*--NO Food Waste Grinder-YES s- NO # of Bathrooms
Automatic Washer ✓ YES NO Other (specify)
E. v1wtank ANK CAPACITY /mcbo Total gallons No. of tanks ~`capacity 400 Total gallons No. of tanks New Installation P--' Addition Replacement- Prefab
Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft.
New*-' Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: LengthS„9 > Width If Depth 34 ' Tile Depth No. of Lines 5
Seepage Pit: Inside diameter Liquid Depth Tile Size Id
Percent slope of land. --e, 2c Distance from critical slope /,f7O
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certifie Soil Tester,
NAME Id J"IIP-1-5 ~l C.S.T. # S.5 and other information
obtained 04om (p• (owner lder).
Plumber's 'Signature MP/ S :5 Phone #115' - 5166,
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application '7 q Fees Paid: State C Co ty C' Date
Permif` Issued/ (date) I Issuing Agent Name
Inspection Yes No Valid* Date Rec' -7 A 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1/76