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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
2
OWNER - TOWNSHIP ,i1~~
SECTION_22'_T_ zf N-R_W
ADDRESS 7X~^ff ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT__Z LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHM.ARK:Elevation and description: # ~pO,Q r
S oSJ ~
Alternate benchmark- j'!'juc
SEPTIC TANK: Manufacturer:_ I~G.Cs- Liquid Cap.
Rings used:,,Q Manhole cover elev: Z'7 7 Final grade elev:_ ?7, 7
Tank inlet elev.: . S Tank outlet elev.:,.2d
No. of feet from nearest road:Front Side
Rear ✓ Ft. ? O
From nearest prop. line:Front Side>LoJI Rear Ft.
No. of feet from: Well~o lye,// , Building:- 3,z
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
w
PUMP CHAMBER
Manufacturer: Liquid Ca ity:
Pump Model: Pump iphon Manufac Pump Size
Elevation of inlet: ottom tank elevation
Pump on elev.: Pump off Gallons/cycle:
Alarm: Man.: Swi h Type: Location-
Distance from nearest rop. line. Front, Side_, Rear-Ft.
Distance from: .W wilding
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width. Length I X' Number of Lines:
Width: /;Z z Area Built
Exist. Grade Elev.- Q7p l Proposed Final Grade Elev. Q,,>, p
Fill depth to top of pipe: /,r
No. feet from nearest prop. line:Front , Side , Rear V Ft.75w
No. feet from well: /tWe No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings use Elevation of botto ank:
Elevation of inlet:
No. feet from nearest o ine:Front , Side , Rear Ft.
No. feet from: Wel , building , nearest road
I
Alarm Manuf urer:
INS ECTOR:
DATE: .1 0 PLUMBER ON JOB: pip,
LICENSE NUMBER: ~•Z~~
6/90:cj
I
IDEPAATWENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON WI 53707 State Plan I.D. Number:
NW4,S0,-,SeC.24,T29-R19 El CONVENTIONAL El ALTERATIVE (If assigned)
Town of Hudson Lo7
Holding Tank ❑ In-Ground Pressure ❑ Mound
NcPermound St.
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
11-I~.-Go
Pauline&Daryl WongertJ 7 51 B sandhill St. N. Hudson W
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
David Fogerty 28 St. Croix 128826
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST -1110-
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PPUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ 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
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
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 DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
E] YES [__1 NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
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:
7 ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
1,3
r
Retain in county file for audit.
Sketch System on
Reverse Side SIGNATURE: TITLE:
i
SBD-6710 (R. 06/88)
I
DID R SANITARY PERMIT APPLICATION couN
U In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / 0
8'f x 11 inches in size. Check if revis on to pr wous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P PERTY OW PROPERTY LOCATION
S T! , NR / E (or
PROPER OWNER' MAILING ADO ESS LOT # BLOCK #
7
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME
w y
II. TYPE OF BUILDING: (Check One) ❑ State Owned ❑ CITY NEAREST ROAD
❑ Public Ea l or 2 Fam. Dwelling-# of bedrooms -L- PARCEL TAX N uMBER( )
III. BUILDING USE: (If building type is public, check all that apply) O
1 ❑ Apt/Condo
20 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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. L"J 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-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 430 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
yro 5" 41s- -3 , O Feet .O Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION Manufacturer's Name Con- Steel Plastic
New xistin Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Holding Tank
Lift Pump Tank/Si hon Chamber
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) 44P/MPRSW No.: Business Phone Number:
~d1 1 dGs'6
-1 if
cr 4 - y
tuber's Address ( tree , ity, State, Zip Code):
I OUN /DE ARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issui Agent Signature (No Stamps)
N A0 Approved ❑ Owner Given Initial Surcharge Fee) b-f(/J1
Adverse Determin ion C`
I :L~
X. CONDITIONS OF APPROVALIREASONS 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 lif,ensed .
pumper whenever necessary, usually every 2 to 3 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:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelli lg.
Ill. 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 fcr 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 pre`ix (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; replacemen` 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 los:,; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption s,/stem if
required by the county; E) soil test data on a 1.15,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)
• APPLICATIOH FOR BAHITARY PERMIT
9TC-100
This application form In to be eomplatod in full and signed by the ovnet(s) of
the property being developed. Any lnadoquacles will only result In delays of
the parmIt Issuance. -Should this development be intended for tesalt by
owner/contcactor,(spec house), then a second form should be tatalned and
completed when Elio property is sold and submitted to this office with the
appropriate deed recording.
r-----------------------------------
_ -~A r l oL(T,_ w rl C-z5e1/T_^
01mair 'at property
Location of property 1/4 S^ 1/4, $actlon Z T JI•R
Township
Melling address / 5~ /3 /91'1/~ivlGL..7-
A1vCIS- W GO 15 . S_qz) l 4r
Address of alts
•ubdlvlslon name_ .SU/I f~ID~~ •
Lot number ~T-
Previous owner of property _ ~ l AA4r-S 4- ~114R 1/ VSGi4- Total size of parcel - a 7
Date parcel was created
Are all corneas and lot lines identifiable? Yes 0
Is this property being developed for resale (spec house)? Yes o
i
Volume and Page Number as tecotded wlth the Rogistee of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOW)NOt
A WARRANTY DatD which includes a DOCUMENT NUMORR, VOLUME AND PAOt NUMatR, and
the RNKL OF THE R9018TRR OF DRRD9. In addltlon a cettitled
~ survey, if
available, would be helpful so as to avoid delays of the reviewing process. the deed description references to a Cettlfied Survey Map, the Cottfied
Survey
Map shall also be requited.
PROPERTY OWNER CERTIFICATION
I(We) certlty that all statements on this form are true to the best of my (our)
Rnovledgel that I (we) am (ate) the owner(s) of the property described In
this lntotmatlon form, by virtue of a warranty deed recorded In the Office of
the County Registst of Deeds as Document No. _n 2L ?76 . I and that I (we)
presently own the proposed alto for the sewage disposal system (cc I (we) have
obtained an easement, to run with the above described property, tot the
consttuction of sold system, and the same has been duly recorded In the ottice
at t
he County pollster of Deeds, as Document No.
V01 A A, /A )C
519natuce of o 1i c Signature of Co-owner (11 Applicable)
~D &~/qb
Date t 819 aturs Date of Signature
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SEPTIC TANK MAINTENANCE AGREEMENT w
s St. Croix County ~
OWNER/BUYER L 0
ROUTE/BOX NUMBER Fire Number o
CITY/ STATE j~UU
PROPERTY LOCATION:*.* k,.SK) k, Section, T N, R W
Town of S~~CJ St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes., Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licetvs~ed 's'e tic tank pumper. What you put into
the system can a ect t e unction o. t e•aeptic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents-M~y be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whit 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 's s 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-
less than 1/3
essary), the sepc~illkbe is
Certification form
three year expiration. y
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural oSt. Croix Certification
and
County a Zoning Office t within completed 30 days
..and returned to the
of the three year expiration.date.~ l
SIGNED A )n
DATE )0
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
If~ID41STRY,. DIVISION
Lf BOH AND 1 P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: TOWNSHIP LOT NO.:BLK. NO:: SUBDIVISIO NAME:
Nw V/sw 1/ z4 /T29N/R /9E (or /,lu 4s6 ? ~uN Id~~
COUNTY: 65.1el"I BUYER'S NAME: MAILING .
USE DATES OBSERVATIONS MADE
NO. BEDR : COMM R PT O I Residence uNK New ❑Replace SEAT16 /990 9 AMC 1=
- MMISQ_
RATING: S- Site suitable for syste'm' U- Site unsuitable for system OUND: OToIONAL: u M®S E1U ING[S DUR TZS ❑ULHOOSGHU CdNVIL TIOk.ALTEM_Q~ofl
0S ?~k►JCNES
If Percolation Tests are NOT required DESIGN RATE l If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: CL 1 Floodplain, indicate Floodplain elevation:
kc~ PROFILE DESCRIPTIONS
BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 't% ELEVATION OBSERV D EST. HIffFrFSF- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / 7S 9~.7! ? 12"g S "Be L30'Be-Ms~4Q 9' as AS V_~ -r 14 B ' ' 933 9~.Z~ loo > 4.33 ,o'' ~~Lrs ~'Be~,S~ 74" Q r~s+~t~
- n,s
B SC ee~/`+~tG 3~"gt e,.es K
B- i\6 r _n.. _L-rS ge,, S, L -7 11
B 9.►7 97.~~ 6 N g./ n, ' LI-SZSIDE"~-L i8"e~.cs Gr 9" &Q,CS
B- .S"~ ~ ~'.S~ "Be.cTS ~3"' eNSC i "8awe.sEG,e 7 aw ~S~lG~2
B_
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEV L-INCH ES RATE MINUTES
NUMBER LlkftrCS AFTER SWELLING INTERVAL-MIN. PER INCH
0 -3 -Z
P_ -L 3.60 ' L73 > >Z <
P_ 3 z.Zd N0 >Z > >Z G
P-
P_ L vA-TI0 A-T QQC,
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. e--IL '-ajQ
SYSTEM ELEVATION g4.00 °'`\'►.)c_!ai~±~.k. -Tod' o~ V'k
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PIP[; AT NW Low' $ Z
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I, the undersigned, hereby certify that the soil tests report e&on this form were ~I J me in accord w' h the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location-ofttt~ tests arefOrre to the best of m knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Q say N S / SEpr~>hla~~ z7 1990
ADDRESS: CERTIFICATION NUMBER: PHONE N LIMB ER(optional):
467 N a ST ) S4oi6 3 o€o
CST SI TURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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