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DEPAA~TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
' P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
ND~~; -M NO~ , 2 6 , T 2 8 -R18 State Plan I.D. Number:
(It assigned)
Town of Kinnickinnic El CONVENTIONAL El ALTERATIVE
Evergreen Dr. ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Steven Huppert Lot 29, Cudds Ct., River Falls, LI
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:
Thomas Wang 3231 St. Croix 128799
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ 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
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: JPUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ 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 101-
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: TRNO.OF ENCHES: DISTR. PIPE SPACING: MCOVER ATERIAL: INSIDE DIA.: # PITS: LIQUID
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;
El YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES E:1 NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO INEAREST-~
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
I
SANITARY PERMIT APPLICATION
ILHR In Eaccord with ILHR 83.05, Wis. Adm. Code COUNTY
v
ST C~ev ~ ~c
STATE SANITA PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than //v~C~ G/ 4
8% x 11 inches in size. ❑ chZk if rev sion to previoLa application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
erJ J. / / LA_ r°/°C-h)W1/4 rJC 114, S ~2(° T,29, N, R F E (o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/ e 9 C~ vas C~ U-2~
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILD NG: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE
OF. 1 P")/V C CV6/L G-/2 6& v RSV
❑ Public 1 or 2 Fam. Dwellin of bedrooms PARCEL AX NUMBER(S)
Ill. BUILDING USE: (If building type is public, check all that apply) 10 7
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
40 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) I~
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. Ia 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 1:1 VauItPrlvy
p
14 El System-In-Fill
IO K 3~
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
Feet Feet
VII. TANK CAPACITY Site
in alIons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank D
Lift Pump Tank/Si hon Chamber
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): Plu ature: (No Stan ) M Business Phone Number;n
ZLy,1,4,, - &_Vil
Plumbers Address (Sjreet, Ci , State, p Code):
1X. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
/
Adverse Determin tin / ` V CvJ
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 <i 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 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
tank§ 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)
L
. APPLICATION FOR SANITARY PERMIT
STC-100
This application Earn Is to be completed In full and signed by the owner(s) of
the property being developed. Any lnadequacles will only result In delays of
the permit Issuance. "should this development be Intended lot resale by
owine be tt
ined and completedtrwhentitheeCproperty Istsold andssubmittedrto hthis officetawith the
P
appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - -
Owner of property
Location of ptopesty -,44-/4/ 1/4 r_1/4, Section 2 T 'a y
Township -V~~~1`(-1`~ J
l* c~ C v.C~C~► C~ - Cn~ C i S
Walling address
Z~
Address of site 3 S~ 1:-k E.' ~aeegn Qr ,Age,-
•ubdlvislon name
Lot number
%
Previous owner of property ,~e~' P•~rly..Y~~l
Total also of parcel ~I-
Date parcel was created X10, Y~~'1 I (~I $
Ate all cornets and lot lines Identifiable? an 0
is this pcopetty being developed tot resale tapec house)? as -=No
Volume /t 3 f_' and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DRID which Includes a DOCUMENT NUMBER, VOLVNS AND PAOR NVMatR, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, it
avallable, would be helpful so as to avoid delays of the reviewing process. It
the deed description references to a Certified Survey Map, the Certified Survey
lisp shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) cettlfy that all statements on this form ace true to the best of my (out)
knowledge= that t (we) am (ate) the ownet(s) of the Property described In
this Information form, by virtue of a warranty deed recorded In the office of
the County Register of Deeds as Document No. 4•¢ S 7.19 t and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to tun with the above described property, tot the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deed, s Document No.
s gnature of owner Signature of Co-Owner It Applicable)
bate of signature Date of Signaturs
000USa ►T No. ATR "A Of C WIWOMM IPORK s M 'we 1 -
445719 ppeeg~ C
~
VOL OJ _PAR516
torte
bed
le , erso-----
~'irainia F. I uAn~ert,-- a
F8 wT IN t•
. . 2:00 P M
aaitdaims to Steven 'T' I u1 L ert, a sine le r er ,or. 4
.
.
the following described real estate in °t r._.~.ro.l}:-.---- County.
_ f
state of Wisconsin : RLT V RN TO
Tax Parcel No:
The I:est CS ; 57 feet 0f tae 'dortj.`. ebt '.uartcr ( ] o` the
/ ^4'GI:~`'-`;1}: )
Northeast uarter ("I C F Sectior. C l7m,nshin
Tkenty-einht (2^) "orth, ^anne Fir-Moen t.e:'t.
SuYject to easer"ent over FouLherly i ortic,ns ^al I-•arcel For
town roac• ;purposes •
Containing 20 acres, r'ore or lcs:~ .
Given in accorCance %-Ath Civcrce c'ccrc-i ar(" crCer c` :-ro:'crt.r
settler'.ent entered Decerler ] 3, ]^"r, ricr,-c c ount- "i.,cor.'31n..
f E ~t
S .r
.
is net
This . • , homestead operty.
(is) (u not)
Dated this day of
f
(SEAL) (SEAL)
-Z -.t
(SEAL) (SEAL)
•
AUTHENTICATION ACKNOWLEDGMENT
It
II Signat~ue(s) STATE OF WISCONSIN
sa.
_ - c r C County.
, Personally. came before me t~o rrRY........ day of
authenticated this . . .day of . - - - 1 . _ t "
19.. the above named
TITLE: MEMBER STATE BAR OF WISCONSIN _ r
(if not, .
authorized by 701.06. Wis. SUAS to me known to he the person Ivvh~x t/4l'fth y'
fore*v~14)`instrument and acknowle4ge tV.y►m 14
THIS INSTRUn•ENT WAS DRnr7FD By / A•~/ /
i'1 VCr ' Notarv Public County, Wis.
(Signatures may be :wt• enticatcd I r :uknuwledccli. Rl,th M Commission is permanent. I if not, state expiration
are not necessary.) date: 19 )
iK,eJ .m-
•Namea of persona aiinina in any r•pa(~ity .h-'d Lr tf I....1 r Yr;nh-1 L.I, w h- r
sT %TF 11%a ut NISI OXN 1% Stock NO. 1.
M.GWN,Ce ow FORM No. I 1993
c~
• SEPTIC TANK MAINTENANCE AGREEMENT rt
St. Croix County r
7 r ~;1 . N ~a r r' w
OWNER/BUYER
O
J
, 4Gwr ? Fire Number 97
ROUTE/BOX NUMBER 2 '~7
r' 11 ,
CITY/ STATE -V`00 , P,~ V_;_ La ZIP L1 C)
PROPERTY LOCATION:'.' IJ*W Section TN, R_LLW,
Town of T=h, 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 licen's'ed' 's'e'pt'ic tank pumper. What you put into
the system can affect t e unct on of the•septic.tank as a treat-
ment-stage in the waste disposal system. •
St. Croix Countyy residents maybe eligible to recieve a grant for
a maximum of 60% of the cost-of replacement of a failing system,
which was in operation prior to-July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new '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-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year-expiration.
H
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as.-set by the Wisconsin Depart- w
meat of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration.date.
SIGNED
DATE ,1d_ 9O
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
C 8
EH, I 5 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES * 9
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH RfcEw I
P.O. BOX 309 c
7 19W
MADISON, WISCONSIN 53701 : ' DEZONING
REPORT ON SOIL BORINGS AND PERCOLATION TE TS LOCATION: N0 ffEF%, Section A, T41N, RLt E (or~fownship or Municipality Nt►1 IM / OFFICE
t.Cr`Y
Lot No. Block No. County
~ r~ Subdivision Name Zr
Owner's Name: p!" /
Mailing Address: fit 01 P(ser L ~Ar k/13
TYPE OF OCCUPANCY: Residence - No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW A ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 0U. 111,M0 PERCOLATION TESTS ~p~b
SOIL MAP SHEET 7 SOIL TYPE TJ" m
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS ICHARACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-, y4 fed fio b e d Qet i
L_sl'
P-~ ay%, PIa~'eC~ q,tq 0
~o ~ S S~ocv ~
0 A-4 'h I 'h
SOIL BORING TESTS Pert rare 040
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
a S b n yql
B- I /I s a ba NdNE 10"
/1"6149 F" 91,65
B- 131 L'S t" Bitf•S 43
~V 06i S 7' 6h" W41 5'
b 1~ vi As 9" Sn O ge s
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of sui ab a areas. ndi t e e 4 umber of square feet of absorption area
needed for building type and occupancy. 6 15 44 1~g Indicate scale
or distances. Give horizontal and vertical reference points. I is a slope.
Q e5e
S11
ah fi c
of 'Y T1
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L0 A V-
1.4
o
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tic, i r--
- - - B -
F 614 f E rr e Of. or
14 Q
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) 6IY "S Certification No.
Address /Co 0 ! `
Name of installer if known
C0T1Y A - LOCAL AUTHORITY CST Signature
~rd~osed
Weir AA
CresenA i,eoo
~a~ Se ftjc
Fvvi-i StSfielv~
d
1ao
a
Area ,p
Ele0,
ice
t° Not
d~ ~ o C v•evr i rrern )Dr.