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HomeMy WebLinkAbout026-1001-90-201 Form - S T C - 104 i AS BUILT SANITARY SYSTEM REPORT OWtfiER`"' ,I . TOWNSHIP SEC. TN-R N ADDRESS ST. CROIX COUNTY, WISCONSIN ! SUBDIVISION Eicc~~ LOT , C___ LOT SIZE _ . r____. _ _ PLAN VIEW Distances and dimensions to meet requirements of ILHA 83• t SHOW EVERYTHING WIX*N 100 FEET OF SYSTEM ry , ~vf A ~...•,t i .int. . • ~j I • , ifs i/< /J ••.t 9i. fr .}fl:If, t,1 . t•i Itt ,r ~ mil, ' . SKI? D scf INDICATE NORTH OW 1, L t' BENCHMM: Describe the vertical reference point used /'0/~ , Elevation of vertical reference points Jen.9jf) Proposed slope at site: SEPTIC TANK: Manufacturer: ' quid Capacity: '-'--'-Number of rings-used:' Tank manhole cover elevation: 1p M; • Tank Inlet Elevation: Tank Outlet Elevations Number of feet from nearest Road: front de Rear, ,~~Si+V • 0_feet • Froth nearest- property line : : Front toSide r,~ ~~1-- feet Number of feet from: well _ uildings r a. (Include this information of .•thew~ bov Lit) ( 2,-Yeference dime tt gotta to septic tank) `SEE RB SE SIDE r • PUHP CHAMBER " Manufacturer: Liquid Capacity: .Pump Model: Pump/Siphon Manufacturer: Pump Size _ Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycles Alarm Manufacturers Alarm Switch Type: •Number of feet from.nearest property linei. Frond, O Side. O Rear. Ft. 0 'Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION •SYSTE H : Bdds• Trench: ~ Width: Lengths ~ ~.'.Number 'of Lines: Area Built:-Z25:/-? Fill depth to to of pipet Number of feet f om nearest property lines Front c Side, Rear.O O Q rt. Number of€est from well: N or of feet from buildings (Include di tances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of'seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytemst (CFeck one). r HOLDING TANK ' i Manufacturers Capacitys c ' Number of••rings Used:•Elevation of bottom of tankti`` • Elevation of inlet: Number of feet from nearest property lines Front, O Side, O Rear, 07t.... ' Number of feet from well: Number of feet from building: Number of feet from.nearest road: Alarm Manufacturer: ~p Inspector:. Dated: - Plumber on job: • License Number: 3/84:saj DEPARTMENT 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 I.D. NW 4 j SW 4, Sec . l , T30-R18 X Number: CONVENTIONAL ❑ ALTERATIVE It assigned) Town of Richmond ❑ HoldiingTank ❑ In-Ground Pressure ❑ Mound 'D A 'W Of~Pr- A E RMI DER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Anthony G. Milliron ~56 N. Green Ave., NEw Richmond, W BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: 966, o~ CID, Name of Plumber: MP/MPRSW No.: ounty: Sanitary Permit Number: Calvin Powers Jr. 1563 St . ' x /lip 10 SEPTIC TANK/HOLDING TANK 3.S$ t Co Xr = 6'54') ( - MANUFACTURER: LIQUID CAPACITY: TANK INLET E IM.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER ~n PROVIDED: PROVIDED: 1, /I 02D /a,), a /01. Y-3/ YES NO ❑ YES NO BEDDING: VE#PDIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL ILDING: VENT O RESH a- ALARM: FEET FROM LINE: . , t AIR INLET: -1 YES NO 7`~ ❑ YES NO NEAREST J~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO E] YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ 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 SYSTE 8,3 ~)oA m o{S S~e~ _ ~ NO. OF TRENCHES: DISTR. PIPE SPACING: MOVER A~EWAL: PIT INSIDE DIA.: # PITS: LIQUID BED/TRENCH WIDTH: , DIMENSIONS , Sa / ~ I GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: y~~~•i 41 ~p/C PIPES: LINE: AIR INLET: FEET FR - o?? 7 U $ o* N T xs 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: SEEDEb: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH 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 COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST to cn C, Sketch System on Re in in county file for audit. Reverse Side. SIGNAT E: / TITLE: I , SBD-6710 (R. 06/88) /Q/ ~DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON STATE SANITARY PERM T # -Attach complete plans (to the county copy only) for the system, on paper not less than El Ic2p //_3 8% x 11 inches in size. Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATI PROPERTY OWNER TAM" ROPERTY LOCATION '/tcv '/a, S T , N, R (or ROP TY OWWNS MAIL G A SS LOT # BLOCK # g, _v CI , STAT ZIP COD PHONE NUMBER SUBDIVISION -N E OR CSM NUMBER Op 11. TYPE OF BUILDING: (Check one) CITY NEAREST OAD ❑ State Owned ❑ VILLAGE ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PARCEL Ax NUMBER(S) (o _ 1 OQ 0 1 111. BUILDING USE: (If building type is public, check all that apply) /O C 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 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) A) 1. New 2. ❑ Replacement 3.E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - 3 Oa Date Issued 5 -'l6 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( q ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet 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 Lift Pump Tank/Si hon Chamber 1:1 - F-1 IJ E3__ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instal latio he onsite sewage system shown on the attached plans. Plumber's N e (Print): 113lu is Signa : ( o Stam ) MP/MPRSW No.: Business Phone Number: Plumb s Address Street, ity, S e, ode): IX. OUNTY/DEPARTME USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing m nt Signat No Sts s tL_ Approved El Owner Given Initial Surcharge Fee) 7 Adverse D rmIn tion 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 3 years. 6. If you have questions concerning your onsite sevrage 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. 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 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; "riction 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 fgrm; 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 APPLICATION FOR SANITARY PERMIT STC - 100 his application form is to be completed in full and signdd by the owner(s) of the roperty being developed. Any inadequacies will only result in delays of the permit ssuance. Should this development be intended for resale by owner/contractor, ("spec ouse"), then a second form should be retained and completed when the property is old and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - er of Property h'IIL-"/L.aK Location of Property ~k sw k, Section , T 3o N-R W Township {`1C OMOWO Mailing Address 11;1; ~1?-1V1-tJ Q,CW µv two 1 $o t'1 Address of Site 90 4-4 TE N,c-w ~c.NMdN~ , ~V~ S4o Subdivision lame (~i~l~1e✓O ',-?tAQ~/~V ~i UEYD OS - 2b -va-1 LAG *47,(oa14 Lot Number ~i Previous Owner of Property ~it7 T. Damv-' E _ Total Blue of parcel -1C' SCAMS . Date Parcel Mee Created q Are all corners and lot lines identifiable? x Yes No to this property being developed for resale (spec house) ? Yes No Volume -7(05 and Page Number 1(o to 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 1 (10d celUA6y that att atatemen.tz on thi'A onm ane true to .the best o6 my (ouh) hnawtedge; that T (wel am (ahe) the (nuneA(A) o6 the phopehty ducAibed in thiA .in6olmation 6ohm, by viA-tue o6 a waMan.ty deed kecokded in the 06 ice o6 the Count RegiAten 06 Deedea~s Document No. _{Zloc,o ; and that I (We) pheeen.tty c.un tl~e plopoaed atte bon .the sewage diA- 04 aya em (on I (we) have obtained an eahement, to tun with .the above deg cpti.bed OopeAty, 6oh the eonatnuction o cid eystun, and the game has been duty hecohded -In •the 066.Lce o6 the County Reg a•i.ateh o6 Pttde, ae Doeaa a tt No. 47-l o0 0 1. SIGNATUkE OLD ER SIGNATURE OF CO-OWNER (IF APPLICABLE) L n~'r0 Qif~lsAn - • r/1Nrew~ Vft&Aa. woes 5001 16 'AAEMB " STATE OF WISCONsiu T. CROTX' COUNTY, CIRCUITCOURT PROBATE BRANCH SALE OF REAL ESTATE.OF PERSONS UNDER LEGAL DISABILITY-DEED BY GUARDIAN. WHEREAS. On application to the Circuit Court of c+- r~rn i Y County, Wiscomin, to sell all right, title and interest of Leo T. Oomke, also known as Leo Domke Sppndthrig , in and to the real estate hereinafter described. such proceedings were ~i~t.~~{iw~ya~w :aweow~newd.~ had that the undersigned was duly authorized as_e „cry i guardian to proceed in said matter: ii+rsere ~+9Qea~a*'~'~r-+''Beners~i- and whereas, the undersigned, as such guardian, has done or caused to be done ail things necessary and required to be-done by law in such cases made and provided. before conveyance of such real estate may be made: and whereas, the undersigned. Lois FTandrnha-n , formprl 7,ni c Ac=1 r►nc3 , as such guardian. was duly authorized by order of Court herein dated on the l6 th day of D ,•ovnher 19 Rf;. to execute. acknowledge and deliver to Derrick Construction, Inc. a deed of conveyance of all the right, title and interest of said Spendthrift in and 1 t n~r"olh+ar"~eom►xtYnG-'1 to said real estate: NOW. THEREFORE, I, the said Tni c TTanA?-Ahar,y ~nrmArl f T.ni c Ac.-n11inri , by authority of the- Court above named and in my capacity as such guardian. in consideration of the premises and of g; x3~Tlt, n„c a n r~ _ r' n , n n n nn) Oollars to me in hand paid by the said Derrick Construction., Inc. , do hereby grant and convey unto the said Derrick Construction, Inc. ail the right, title and interest of the said Leo T. Oomke, also known as Leo Domke ~c~pnd hr; ft in and to the following described real estate in Sf- _ (`rf.4 v cln~~arr+ar_~r-~n~aMpater+t=-r- • County, Wisconsin, to-wir. The Northwest Quarter of the Southwest Quarter (NWT of SWh) of Section One (1), Township Thirty (30) North, of Range Eighteen (18) west. • MGM= OFFK . CROIU COW WISE 'a cL for Re=vd I& 2nd " CT Jan. .a As 7eelrler M Oeeare. File No. No. ISP -SALE OF REAL ESTATE OF OERSON5 UNDER 6.EGAl, 015ABILITY. OEED BY GUAA09AN, chanter 296. -Nor INK 16apiaE167 0 a drahan . formr. y T.o ; c /ASp1U-Auardian aforesaid, this T.n; is Hari e WITNESS the hand and seal of said ~ 22nd day of December , 19 86 In Presence of ISEAU Lois Handrahan, formerly Lois Aspl d. General Guardian of ! Iwwrr'~6p~ws►'~e►~6swsia►~ ~ 1 Leo T. Domke, also known as Leo Domke, Spendthrift STATE OF WISCONSIN, SL St. Croix County. . 4Y of December ,Ao.t9 86 Persoealltic• cams before me this 22nd the above-named. L©zs Handrahan, formerl Asnlund uardian, to me know rrto.be the person who executed the foregoing instrument and a nowiedged the G he exect~ eby virtue of the authority aforesaid Tanya . Glaser - NotaryPublic. St. Croix My Commission Expires H 'L. y r r I v SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County o ' ot1 ~lL > RR~1 UG 6,00 izvt C OWNER/BUYER ,pr,~~ya~.►y U•~t.~.1+~P1 I~ ROUTE/BOX NUMBER CJr1e4-,Q AVC Fire Number ` CITY/STATE law V4C,4-VMoMO ~N ZIP 47tari I P'?OPERTY LOCATION: NW ' , '5V V4, section T la N, R W, I Town of _V1 44*A0140 St . Croix County, Subdivision 4,i '%4ayEy , Lot number 2 1 ' L,F-D 0 a, Do c, i' 4Zb o 9- I Improper use 9nd 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 put 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 C E I/WE, the undersigned, have read the above requirements and agree Cn to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- u 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 - I i DATE I St. Croix County Zoning Office P.O. Box 227 Hammond, WI 54015 715-796-2239 Sign, dare and rer_urn to above address. bEPARTMENT OF REPORT ON SAIL BORINGS AND SAFETY & BUILDINGS IvNDUSTRY, DIVISION LABOR AND BOX HUMAN RELATIONS PERCOLATION TESTS (115) MADISON W 53907 (H63.090) & Chapter 145.045) MCATIOPJ - SECTION: I OWNS HIP,jdkk&WCITY LOT NO.c BLK. NO.: SUBDIVISION NAME: - Ats 1/4 SW1/4 1 /T30 N/R 116,4 Richmond J 1.n/a n/a COUNTY: OWNER'S/ NAME: MAILING ADDRESS: _St. Croix Derrick Const. Inc. -.R.#I, New Richmond, Wi. 54017 - USE DATES OBSERVATIONS MADE NO. B DRMS.: COMMERCI f I DESCRIPTION: PROFIC~DESCRIPTIONS: IFERCULA ION TESTS: -Res;dance - n/a :®New ❑Replace 7-16-90 7-16-90- RATING: S= Site suitable for system U- Site unsuitable for system ~ ~ - Tl~ . M . 6R-60-4-51 R R : S~ _A1 -FILLHOl❑DING T-AWK: R ECOMME NDED onal S -YS I PA :(optionall C_~=--~~ __-JC U -S ,'J]US- (y U conventional f!f Percolation Tests are NOT required DESIGN RATE: If any pcrtion of the tested area is in the 11-ilider 0463.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 28 SHA - BORh\IG TOTAL DEPTH TO ROUNDWATER-INCHES CHARACI ER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEFTTHXX ELEVATION OBSERVED EST. IGI4EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13 _1 7.59 104.47 none >7.59 1.17b1.1. 1.42bn.sil. 1.33bn.s.1. 3.67bn.c.s. B 2 7.34 103.44 -none >7.34 .92bl.1. .83bn.sil. ,.92bn.s.l. 4.67bn.c.s. 3 6.99 103.83 none >6.99 .83bl.1. .83bn.sil. 1.00bn.s.1. 4.33bn.c.s. B 4 6.67 1.03.02 none >6.67 1.08bl.1. .67bn.sil. 1.171in.s.1. 3.75bn.c.s. B 5 6.50 102.55 none >6.50 1.00bl.l. .75bn.sil. 1.25bn.s.l. 3.50bn.c.s. B- deicmalt PERCOLATION TESTS F I DEpT-H WATER IN HOLE TEST TIME OPOP IN WATER L V L-INCHES RATE MINUTES ER AFl ERpOLING INT3RVAL-MIN. pERb v t PE7RIOD PER INCH P-- 2 - -3 - - none - -----s-- V6_-- _ _Vs 3 y : 36- - - none - - - 6-- - 6 - 3 - - 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 percen, o' land slope. SYSTEM ELEVATION 100.47 6- A ~ z +21 t ° ,g Ck, )00 i he undersigned, hereby certifv that the soil tests reported on this farm were made by me in accord with the procedures and methods Specified in the LNisronsirr dminktrative Code, and that the data recorded and thn_ location of the tests are correct to the best of my knowledge and belief. NAME. (}:rri+N) - --a--------------------- 'TESTS 6VERE COMPLETED ON: Es-y L. Sr.ee1. 7-16-90 Uf.iF7F'S;S: -----CF_11-1-1FICATIONNUMBER: PIIONENUMSER(optional): 988 N. Shone Dr. , New Richmond, "Vi. 54017 229 V 1 71 -246-6200 CST SIGN 4t E EllS7R15U FION: Original and one cr,pv to 1_ocr l Authority, Prgp,:rty Owner and Soil Tester. t3 ;161 (R. ")~'/F2! Cll!EY; - - I I 1 11011; i T 4- L - - - cam' _ - - - - - I 1 ~ i I r I I j - - - - - - - - - - a - - - - - -I -i { : 10 - - - I I I_-..._ _ - - - - I , i - ;.--r - - - - - - - - - - - I i I I I i _ ~ I i 1 ' ' I - . I ! I II~~ ~ } ! , I I I I I 1 I I ~ I J I '-1- ~ ' - I - I I 7- - --T- I' I I ~ I I I I 1 ~ I I j I I i I I ! I 1 ! ! I i - I I I i ~ I + ~ I I I I I f j I I I I~ I I I ' i I I ! 1 ~ ' ' I ~ I I I ' ! - i - - -I i - -1-~ - rll T I ~ I I I ~ I I I i I i I i j I I i I I I I I i_ _ I I I I j I i i ! i I ! I I I i I i I i i~ i ! I I T ' I I i I ~ I - 1 I I IT ~ r I ; II I I ~ i 1 I I I ~ I i I I I I ' I I I I i I ~ ~ I - - - - - - - T i I I I I fil ~ II I I I I I I I - - A It - - - ---I -1 - - t -1--- I _ I r-- ! ' PAGE OF `r SS Se.C}IV1, o~ 3e1~ S~ste~-~ AOVAk, / Jq /yam helih Alr Wall, And OD►a(vollon Pipe ,~~f '1 ~~✓I(i~' ~ C__)"~ App(orld Vonl Cap 41 G Ora final final Geed* 20. 12° Above Plpp - 4- Cool lion To final Goods Vonl Pipe "won Hay Of SLmholk Coveting eun 2r Ayp(opole ' Ora( Pipe 01e1(IDullon Plpo -T o 0 0 - Too - alk Pipe o B' Aggeogais BencaJ Plp Po(lo(aled Plp$ below 0 -Covpllnp T«minallnp Al • Balloon 01 31614on ' C~rr.c~t Prp~o~ep P, no- g0snvw SOIL FILL DISTRIBUTIi PIPE pJuTM APPROVED i7 ETIC COVER c ~"'--/1ATERII~t- OR 4" OF STRAW 2" OF AG69EGAlE--/mar OR MARSH HAS t> OFIz-Zl/zAGGREGATE ELEV. 0F~FEET--.-.,- t DISTRIF5UTIOU PIPE TO BE AT LEAST INCHES BELOW ORIGINAL GRADE AQU AT LEAST LO INCHES BUT 1,10 MORE THAKI 42. MUMS BELOW FINAL GRADE MAXIMUM DEPTH OF F-)(CAVATIOO FXOM OK16WAL 6XAoF- WILL BE INCHES MNIMUM Ocr" OF EACAVAT"ION F-KOM 01~16INAL. GRAPF- WILL BE INCHE S SIG►.ICD: LICENSE LJUIABEI1: - , DATE: - - - 110 Q~.HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ec if revis onto previous application -See reverse side for instructiops for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION. PROP RTY OWNER _ PROPERTY LOCATION '/a, S , N, R i(or) W PROPERTY OW 'S MAIL N AD RESS LOT # BLOCK # Cl . rg:2~ ,1/z C2 1 . Z= STAT ZIP CO E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER J'A,,1_4&fA10 141t 1 7v 11. TYPE OF BUILDING: Check one CITY NEAR T RO ' ( ) ❑ State Owned O VILLAGE IM =N OF:. ❑ Public Z 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX N M E III. BUILDING USE: (If building type is public, check all that apply) /D 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. X New 2. ❑ Replacement 3.E] Replacement of 4. ❑ Reconnection of 5.E] 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.) 777 sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION .7-,-9 -<,3 Feet Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite wage system shown on the attached plans. Plumber'~Ne (Printh - lumber's Sig ture• (N S ps) MP/MPRSW No.: Business Phone Number: Plum is Add a (Street, Cli State, Zip C e : Al~f IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag nt Signature (No S ps) Approved ❑ Owner Given Initial /u Surcharge Fee) Adverse D t rmination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety S Buildings Division, Owner, Plumber v 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 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 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. I SBD-6398 (R.11/88) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR NELATIONS \ PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RE / MADISON, WI 53707 (H63.090) & Chapter 145,045) LOCATION: SECTION: TOWNS H I P/NJCK9D0UCKD[X: LOT NO.:BLK. NO.: SUBDIVISION NAME: NW 1/$W1/4 1 /T30 N/R18 I& (or) W Richmond 2 In/a Derrick Const. Inc. COUNTY: OWNER'S AME: MAILING ADDRESS: St. Croix Derrick Const. Inc. IR.R.#l, New Richmond, Wi. 54017 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PRO IL DESCRIPTIONS: R Residence 3 n/a ®New ❑Replace 4-28-87 4-28-87 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNOPRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ©S ❑U ®S ❑U ®S ❑U ❑ S ®U ❑ S ®U conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WI H ICKN SSHA S, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH I LEVATION OBSERVED ES HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 7.59 99.85 none >7.59 1.17bl.1. 1.75bn.sil. .75bn.l.s. 3.92bn.c.s. B. 2 7.33 99.70 none >7.33 .75bl.1. 2.08bn.sil. .50bn.l.s. 4.00bn.c.s. B- 3 7.34 99.50 none >7.34 1.17bl.1. 1.00bn.sil. .92bn.s.l. 4.25bn.c.s. B- 4 7.00 98'68 none >7.00 1.00bl.l. 1.83bn.sil. .42bn.l.s. 3.75bn.c.s. B- 5 16.08 98.92 none >6.08 .75bl.1. 1.25bn.sil. .58bn.s.1. 3.50bn.c.s. B_ I i PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t P RI D PERIOD PER INCH P-1 3.85 none 3 6 6 < P.2 3.70 none 3 6 6 6 <3 P- 3 3.50 none 3 6 6 6 <3 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 ~.i" At ~4T- I o M I / I "s _4 I - Skf'e i 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 COMPLETED ON: Gary L. Steel 4-28-87 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): q88 N. Shore Dr_ New Richmond, Wi. 54017 57246-6200 CST SIGNA I / DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER L-- I ~ ' I I I I ' I I I ! I I 1 I I , , I V I I I l i I I I ~ 1 I ;~IJ , R/ V 7 j/ 1 1 I T~r~ ~-{j I -I ! i - ~ ! I ! I1I I ' i I i I i~ I j I I j! i I I ~ I I i I I , I I I I 1 j 1 I I ~ I ~ I i I I ~ I I I { 1 I 1 I F-~-- 1 --j---- l a a -I-- - - j I I i I. - _ i ~ i ! ~ I i I I I ~ 1 ~ I 1 I I I I I I I I I ~ I l I 1 I - rt- i 1 1 -I-.--~- t I I I 1 ~ I T fl I I 1 I ~ 1 I I ~ ~I I ~ I ~ I I 1 I I I _ I - y-- I - r i , I , - : I : i : i , : I I , i I I i i I ; I I _ i I I i : I - - - - r - - I i - I 1 i ' I PAGE OF CrvSS S~c~It)rl p~ A &o j~ Fr46h Alt Inl616 And Obtervollon Plp• Qom- Appror4d VaM Cop wlnlmum 12' ADOra Fln°I Grad• 20. 42" Abore Plpp _ 4" Coal boo To Final 014d. t Pipe Ma►n Mot Or StnlMlk Co.arlny "l0 2" Ayyrayola OlalrlOrllon O w" Pipe Pipe o 0 0 Tao AOOraOolo Banaalk Pipe ° parlarolad Plpe balav o ~Coupllny Tarmin411n0 AI 6ouom 01 St►lam SOIL FILL DISTRI5UTIOI.1 PIPE • 2APPROVED S`~NTHETIC COVCR MATERIg1- OR 9" OF STRAW "oFAGGR~GATE _ . OR MARS►+ NAB EL EV. OF •,18 1°' OF AGGREGATE FEET t , DISTRIBJTIC)W PIPE TU BE AT LEASTC::J~ INCHES BELOW ORIGIMAL GRADE AQU AT LEAS-PLO IIJCHE,°, BUT AIO MORE THAM '12. IMCHES BELOW FINAL GRADE MAXIMUM pEPTN OF EXCAVAT100 FXoM oKIGWAIL 6KAoF. WILL BE LZALI_ MCHES, milmuM oEPrH OF EACAVATION r-001A. 0~16114AL CjRAPF- WILL BC C INCHES SIGIJED: LICEAISC DUMBER: r DATE: Q'~j Ila • ~7 SANITARY RERMIT APPLICATION _L.,HR 1 In accord with ILHR 83.05, Wis. Adm. Code COUNTY, ;s STATE SANITARY PERMIT # -Attach complete plans (to the county, copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Chs it ®vihlon to previous 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 '/a %,S T,, - , N, R . E (or) W PROPERTYoW R' Girl a Abbll SS` LOT # BLOCK CITY ATE , - IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYP OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned O VILLAGE r OOF: Public 1 or 2 Fam. Dwelling-#of bedrooms- PARCEL Ax N - M E r III. BUILDING USE: (If building type is public, check all that apply) 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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2.E] Replacement' 3. ❑ Replacement of 4.E1 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - bate 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 - Feet Feet CAPACITY VII. TANK Site in al Ions 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 Holdin Tank , Lift Pump Tank/Si hon Chamber E Ej El 1 11 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 Signatures (No Stamps) MP/MPRSW No.: Business Phone Number: u is ddress'( treet, Ci , State, Zip Cod#): . COUNTY/DEPATMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ZDate Issued Issuing Agent Signature (No Stamps) Approved El Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 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 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety S Buildings Division, 6011-2663815. 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. M. 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 a// 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) SANITARY PERMIT APPLICATION QILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check if revision to previous 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 %a, S T , N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE NEAREST ROAD ❑ Public ❑ 1 or 2 Fam. Dwelling- # of bedrooms - P EL TAX N MB RO 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 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-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 Feet Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber Vlll. 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: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-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 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: ti 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. 11. 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, C DIVISION LABOR AN P.O. BOX 76 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 3707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNS H I P/jdd&4§djtW TY: LOT NO.:BLK. NO.: SUBDIVISION NAME: Nw 14sil/ 1 /T30 N/R l rl W Richmond 2 n/a n/a COUNTY: OWNER'S NAME: MAILING ADDRESS: St. Croix Derrick Const. Inc. R.R.#l, New Richmond, Wi. 54017 USE DATES OBSERVATIONS MADE INC. BEDRMS.: COMM R 1 L DESCRIPTION: PROFILE DESCRIPTIONS: R AT ON TESTS: Residence 3 n/ a INNew ❑ Replace 7-16-90 7-16-90 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK: RECOMMENDED SYSTEM: (optional) ®S oU )EIS ❑U ] S ❑U ❑ S )EU ❑ S EA conventional 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: n/a Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 28 SHA BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHXX ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13-1 7.59 104.47 none >7.59 1.17bl.1. 1.42bn.sil. 1.33bn.s.l. 3.67bn.c.s. B 2 7.34 103.44 none >7.34 .92bl.1. .83bn.sil. ,.92bn.s.l. 4.67bn.c.s. B 3 6.99 103.83 none >6.99 .83bl.1. .83bn.sil. 1.00bn.s.1. 4.33bn.c.s. B4 6.67 103.02 none >6.67 1.08bl.1. .67bn.sil. 1.17bn.s.1. 3.75bn.c.s. - B-5 6.50 102.55 none >6.50 1.00bl.1. .75bn.sil. 1.25bn.s.1. 3.50bn.c.s. B- deicmal' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD PER INCH , 1 .00 none 3 6 6 P_ none 6 6 6 <3 -3- 3. 36 p_ none :3 6 6 <3 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 100.47 E . 1~1 ICY) = ~ ` ~ , ! f W"Z E E 1r 1 I r 19 i N -__._4 I _0 i S ( x f sti ,f' 3 I e f 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 COMPLETED ON: Gary L. Steel 7-16-90 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 988 N. Shore Dr., New Richmond, Wi. 54017 229 71 246-6200 CST SIGN E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - INSTRUCTIONS FOR COMPLETING FOR 115 - SRI - 6395 To be a co i,,iete and accurate soil test, your report must include: 1. Comp I script io n; 2. Thie us.ust clearly i :ate whether this is a residence or commercial project; 1 MAX her of bedr( commercial use planned; 4. Is 'Zis ,.,raceme it s - 5. Co tp. _ lity rE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL 01 ARE RUI D ON SOIL CONDITIONS; d. PLE ~V Er writing profile descriptions and completing the plot plan; 7. mi% _ locating your test locations. Drawing to scale is preferred. A k I ievation reference point are clc shown, and are permanent; 3. (.iate boxes i dates, names, addresses, flood pi, p i colation test exernp- 15. 'is flood plain, elevation) not apply, the appropriate box; 11, your current address aric' tific , 1 distribute as re€luire{`. SOIL ;T CAF FILED WITH THE ""'ITHIN 30 DAYS OF C;C ~TION. _3EVIA, _m FOR r,,._ _ :AED SOIL TESTERS ;id Textures Other Symbols 10") BR - Bedrock i - 1011) SS Sandstone 1r - j , ler 3") LS - Limestone HGW - Nigh Gic rd Perc - P ,olati_.. =nd W ~d Bldg B ling Is I cI Grey ter Than sl _ . n < T` in 1 Fan _ *sil - L~,arrz k si - Gr:~y - Yellow iy L,, i - Red y L mot, - Mottles Clay with 1. sic - -y Clay few, fine, faint r- pt - Many, rr.__'iurn r7i - - distinct r t la - prominent t HAIL - Nigh water level, Six t:?=`l^utUr,s surface vie-, r C: sposal BM - Bench Mark VRP Vertical R i VNER: he r ser* may- A s' r Aart of jetlon, 1 r~ l 1 , 1~ ! l CIL',E MAW 01 CONNU bGMW 426074 west line of the SWz of section 1, N0003812111W N 1319.29' N rt cn co w N H t-' D N °z r'r n O O n1 CD o O N yy cn 11 1~ ,p y D c :r :E unplatted lands owned by platter C7 d xl H Cn S0003412711E 627.77' x ro c 590.091 > fCTI oo Cn i `J T O -G o n I -3 cD 37.68' 3 z ( N O In rn 0 c0 o H H ~ x ~ Z rr lzJ o T m M £ S0003412211E 628.231 O ~ 591.06' Hot' o Ic o 3 7.17' Q I 'o O N 2 I r.) co to w ° o z o o i -r y ~,r z x v N I C7 'Do t0 O to N O N d c, to c:~ o I H lTJ Ln O ICA w ! N N 1 3 N I N E I o_ r. < m" S0003411711E 628.681 i o ::E: r lo : 592.041 H m o z 36. 641 i m n O o O -i ° I w o tcD o I I- w frt•. (D '„T I t0 N N O N o I •G 4 In :o I o o W ° o i~ H n a w I co oo - IN z H O GO a ~D 1 V - - / Irt . 1 1 ( Irt O c tD ff I rn y < y o I I 4 tD 3 < 3 S0003411211E 629.131 ~ -o < - I 593.021 o rt - - 36.111 w 0 N O o m rn N N o z W o_ 0 Ln m CD c o n -o < o n o 0 t0 O tD I • o 1-.i~.... i~ co 00 co r 3 16 1 35.591 east line of the W of the SW~ 594.001 - - - I N0003410811W 629.59' = unplatted lands owned by others - z tD CD I :3 I rt. O co IN I N I r✓ r 0 o o o I 0 o o rt rt rt rt ~ W N Q N l~ 4- I c'7 (n I--1 ~ d rr, c-m c-" w3 1Pf ••;a i w w w w m o n x o v C-r r w r) --h z N M N cDr~ = f n S r •q:, I G7 tp W M (D G7 > > 4~ c N I c V w m (D cn Z a o rt. O w w w w w o o r z z o i y { c-~ r c-~ o O o o c m .t m ,e~ ; V V rn o C) CD 0 d fTl 's-•~' o ~ o rt Sr n m ~c- Sp T CD ~ S O rt E m Z N B X C7 (b 0 0 0 (n m I C) Lo M 0 CD d to w c c-) A s o co W - r rt r N r- r7l r• O N rt 3 ~7 w w rD O:1> c - f c t0 (D .N.. i..r n r Va.4'" tD w co w CD L7 rt E lD O. V W co P' (D O) f.l'I ~ rt T7 co -i) O } O _ O n O H n v c r o w W W W W O o =3 ~~n Ln -D~ MAY 22 ;987 rt ~ ~ W N (D \ D. v u N : N 5i. CROIX COOS TY rH CO AKW.iENUVE PAjMS ?jAZ.-441NG Volume 7 Page 1819 ww~ 2t~nING r_o7tFs