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- DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDI G
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
IVl(jQ OI~I~1 5377 State Plan I.D. Number:
SE,, jV~~Ji4 , eC. 27 , T28-R17 ❑ ALTERATIVE (If assigned)
Town of Rush Rive CONVENTIONAL
E] Hol Ying Tank ❑ In-Ground Pressure ❑ Mound
18th AVe.
NAM
Charles Smith E OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
V: yE . PT. ELE ~ r~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT ROM PLAN: REF. PT. E .
Ike . 'd . 1-,kl, 4~ C", C xe 6 X ii J, -1/1, -7 7 &-A
Name of Plumber: M/MPRSW No.: County: Sanitary Permit Number:
Chris Lickness 6964 St. X 14 _--_j 1297 7
SEPTIC TANK/"IIzB#tQ4*A#K: 5, 1 y? '
MANUFACTURER: LIQUID CAPACITY: TANK INLET L TANK OUT E WARNING LABEL LOCKING COV R
PROVIDED: PROVDED: .(o,
R_ rcks 7`16,1 / YES ❑ NO ❑YES NO
BEDDING: V~y~ DIA.: VE#~ MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
1D . / I f) ALARM: LINE: AIR INLET:
FEET FROM
❑ YES NO S~ ❑ YES NO NEAREST
DOSING CHAMBER R. td._~' (-o = 3s'go
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHWMANUFACTU R: WARNING LAB L LOCKING COVER
PROVIDED: PROVDED:
t e J ❑ YES NO t L o I CD vc e y- YES ❑ NO YES ❑ NO
GALLONS PER CYCLE: rlu a 1d~cK , 5 PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BVENTTO FRESH
(DIFFERENCE BETWEEN = 91.$4 ark FEET FROM w LINE: AIR INLET:
PUMP ON AND OFF ao 4. _-~'4 at, ❑ 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: ,v(• {c,, ,-c " • Palo = //.,lf .f-J N -
BED/TRENCH WIDTH: LENGTH: N0. OF DISTR. PIPE SPACI G: COVER INSIDE DIA.: # PITS: [O'EQF UID
IT TH:
r / TRENCHES: IAL:
I P
DIMENSIONS J
41 / -V A--
_T
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: O. DI TR. NUMBER OF PROPERT ELL: BUILDING: VENTTO FRESH
' • / PIPES: IFEET FROM LIN AIR INLET:
BELOV/rPIPES: ABOVE COVER: E~LEpV. fNLET: ELEV. END
(c - /U 7 / 3 NEAREST r7
MOUND SYSTEM:
Mound site plowed perpendicu ar 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:
❑ YES ❑ 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: N0. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
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:
Cq MfM/lENTS: FEET FROM LINE:
et(Q Cy(. ❑ YES ❑ NO ❑ YES ❑ NO NEAREST /
/Z,v<:,C~y ~~~~U~SLGf~z•Yvt-C~'(C'~u"f~'"~~" .c ~ ~ ~i~~ ,i ~r~, j~~;
f, ~ ~ r~~J.<~ ~ ~ ✓ b'.I ~~C!_4~=" C.L. '~~--•-7~~' J Ct-~'(~`
XCG G'f Re iry~ounty file for audit.
Sketch System on
Reverse Side. SIGNAT.URE: TITLE: t
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION /4 70ti
COUNTY
7 0ILHR
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 /C? b _/Y 7
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 L ATION
h rd S 7`fl '/a /1/0%, S -J-. T Z, N, R/ 7 E (or)6i~
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
RI l 4ct __'2 cy4
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
CITY NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE 0S 'r~ A ~
❑ Public Ell or 2 Fam. Dwelling- # of bedrooms AR EL x Nu ER ) _ q,5`00
III. BUILDING USE: (If building type is public, check all that apply) 6,3L,)
1 El 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 120 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. N] Replacement 3. ❑ 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 # - 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
y Z C ?1 skeet l O Feet
VII. TANK CAPACITY Site
in allons 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 / / C' am' LO 8
J El I El
5_70 - kq _LL~ El I El F-1
um Ta WSi hon Chamber / 01
V 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:
/ , ; n z~ 71,5- )4-3 3 o
Plumber's Address (Street, City, State, Zip Code):
IX. UNTY/DEPARTMENT USE ONLY
S ps)
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issuee Issuing ent Signature I :No
Approved El Owner Given Initial f t Surcharge Fee) /
Adverse Determination ✓ \ - I 131
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
I
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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:
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 81/2 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 takes; 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)
APPLICATION FOR SANITARY PSRMIT
0TC-100
This application form is to be completed in full and signed by the ovnez(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended. lot resale by
ownst/contcactot,(spee 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.
• a r~ c---- Jm/
Ovnet of property
Location of property . & 1/1 /4, Section
Township ~fjAe
Mailing address .3 "i-d
Address of alts l 8~3 ~TQ•~
Subdivision nasreZ7 29 i4 /7&~
Lot number
previous owner of properly 1Lfe '0k__+/2N~'
Total else of parcel d 0- C_ ref
Date parcel was created
Ace all cotners and lot lines identifiable? L ..Yes ._J10
is this property being developed tot resale (spec house)? as
volume Z~and Page Number 6.Z as recorded with the Reglstet of Deeds.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
INCLUDE WITH THIS APPLICATION THE FOLLOWINGt
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
8vallable, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Caitltled 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 (out)
knovtedgel that I (we) am (ate) the ownet(s) of the property described In
this Infotmatlon Iotm, by virtue of a warranty 4~) }4~ rec wed In the office of
the county Reglstec of Deeds as Document No. 7f~~ K s and that I (We)
presently own the proposed alto Lot the sewage disposal system tot I (we) have
obtained an easement, to tun with the above described property, tot the
conettuction of sold ayste , and the same has beenA4eard;d in the office
of the County Register of sods, as Document o. YY XX~S
signatute of Owner natu of -Owner (1 Appllca )
Date of Signature Date of Signature
8:30 A
w
whether one or sere).
!I r ~Ow the psaapt and fail par-
ftvtber with the
Wseusle (ad called the "property").
iE,.. rT~r r Coasts sate Of Wisconsin: MIrTuOM TO
.
i n I
Tax Parcel No. l1
section 27 of Township 28 N, Range 17 W.
fi' 1
Qt......... homestead property.
dfM not)
to purebaee the Property and to pay to vendor at .......pldC.. reaSOnab1X_.dg... ed
in the following manner: (a) =.2.S.QQ-e.Q.Q.................
'1i6ie Contract; and (b) the balance of ;..?2 r:.DU •-Q-Q............... together with interest from date
".bs O eabandft from time to time at the rate of............. ...5.%t per cent per annu.n
M fle~owe:
to of principal and interest commencing the Stn day
1986, in the sum of $221.58 and continuing thereafter;
sliceessive month on said date.
bewater, the entire outstanding balance shall be paid in full on or before the....... 5th day of
i
»s....y 19..9Q. ( the maturity date). p
&W,4dault in payment, interest shall accrue at the rate of .$..5.... % per annum on the entire amount
arbisA.A" indude, without limitation, delinquent interest and, upon acceleration or maturity, the entire
~ ~~~~'~'`T SRS7[1~J0007tti1)<714C~ iIL~IOtJ~C~7C7W~CK i!
~ z x>ttlme~tmtdcfotaxX= 911 cixUKXb lc Onmte~vloo~mc
Pff i1tiKi[7ii61kK iiliXS,YoX~L1fa?W Wi7tdHH6iX SM~Ydt1l[~
.R ri1Ci]id[>~~f1{RK~LiC~H~it1S~KlGNifii3iYd;i~[~GKY>Ii1h6Y4CiiYitlhMtYiitc
* sW be applied first to interest on the unpaid balance at the rate specified and then to principal. Any
X Y X XXX XX
ryssesL Bray De psnpeid without premium or fee upon principal any time
:y. "~>rwicY>taeesx
In the s~sb! of Any prepayment, this contract shall not be treated as in default with respect to payment eo long
alb tie wwid belaaes of principal, and interest (and in such case accruing interest from -.nonth to month shall be treated
# *'*Meld ;praelpal) is less than the amount that said indebtedness would have been had the monthly payments been
r
sse~le as sret speeised above; provided that monthly payments shall be continued in the event of .relit of any proceeds
of ararsutoe or ooedemnation the condemned premises being thereafter excluded herefrom.
k
Pi ebaser sates that Purchaser is satisfied with the title a3 shown by the title evidence submitted to Purchaser
restrictions and reservations if any, of
teeessslaatiotaestoept• . easements,
record. See addendum attached hereto for additional terms.
w
SEPTIC TANK MAINTENANCE AGREEPIENT
St. Croix Countyr
I w
OWNER/ BUYER~/i /e S. 3e n ~e r s,•` o
1 b
93
ROUTE /BOX NUMBER Fire Number V
CITY/ STATE Qh-c ►%►2 ZIP rt
e
PROPERTY LOCATION:'_ Wyk, Section n12- P• T_ p R_L?W,
own of k,,SSt. Croix County.
T
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Pro er maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen's'ed 'septic tank pumper. What you put into
the system can affect the--function of tae septic tank as a treat-
ment-stage in the waste disposal system. •
St. Croix County residents-En 'be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
wh c 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 .sys'tems 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-
and scum.
essary), septic-.tank
apthan 1/3 proximately 1 30 of days sludge
sent less
prior to
Certification form will be sent approximately 30 days prior to
form c will k be is
three year-expiration. y
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, asset by the Wisconsin Depart- a'
ment of Natural Resources, Certification form must be completed •,d
and returned to the St. Croix County Zoning Office w~ in 30 days
of the three year expiration.date. E.
SIGNED
DATE-
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
N~E DP K3TRY, TOF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
N
PERCOLATION TESTS DIVISION
LABOR AND (115) P.O. BOX 7969
HUMAN RELATIONS l MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION:
SE TI N: OWNSHIP MUNICIPALITY: LOT N BLK N .SUBDIVISION NA E:
SE '/NJ/ 27 /T29 N R 17 E (or RUSH RIVER
COUNTY: OWNER' BUYER'S NAME: MAILING-ADDRESS:
ST. CROIX CHARLES SMITH 626F/LLMOREsr. NORTHEAST MINNEAPOLIS, MN. 11413
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: FC0M`M-IfRCIAL DESCRIPTION: ~PR FIL D IONS: A NTESTS:
FRI Residence 4 N A New ❑Replace T - 9 - B6 7 - - B6
RATING: S- Site suitable for system U- Site unsuitable for system
O VENTI NAL: MO ND: IN_ -GR N ESSUR : S ST -IN- ILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
MIS EJU S 1U CIS ~U El S MU o s Elu CONVfN710NAC
If Percolation Tests are NOT required DESIGN RATE: LF'loodplain, any portion of the tested area is in the
under s.H63.09(5)(b), indicate: CLASS / N A
indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION PTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
/ 3.8' N,A• NONE /.6' On/ /0.9'1 On s///0. 798a r// w/ccp R mot /2.2'1
B- 2 1.2' a 2.01 Bn/ 8'1 On //.0'1 On s// w/cc R mot /2. 4'J
3 6.6' N.A. NONE 2.7 1 On / / 0.7'1 Be /s and or /2.0'1 On s// w/cep Rmot 1/.3'1 en r/ w/ccp
B- Rmo/ to. 4'J On s and or/ 2.2'1
4 1.01 N.A. NONE /.9' Bo / 1 2 9 Bo sI to.7'JBn s/ w//1/ R mo/L0.9'JBn w///tRmW/2.2'1
B 1 6.2 /00 1' NONE 7' 6.21 Bn//0.6'1 Bn s /0.611 an s/and r/1.0'1
6 d.B1 /00.61' 1/ 5-6.81 8n//O. B'1Raw t1.0'JBns/ ond_yr/1.0'1
B' 7. 6 / ' 4
y 7.6 On s fO-fi'JBfi r// ' B 111`6. 39
1
9 6.7 /0/.711 H Y 6.71 Bn / / /.0') Bn it or and st / 5.711
B- 9 6. 1' /O/. 01' 1I 6. 1 / on / /0.6'1 B s .9'
B- - -
SOIL sHEET 93 PERCOLATION TESTS CHETEK ONAMIA COMPLEX
TEST DEPTH WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES, RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. p 1 p RI PER INCH
P- / 2.0' N O N E to 411 3 112" 3 314" . 3
P-
P- 2 2.6' NONE /0 23/4" 2 1//6" X10 4
P-
P-3 2.2 NONE /0 4///6" 43116 411 3'
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.
/N/T/AL 98.41
SYSTEM ELEVATION REP. 99.00'
_
^X~T rENC B SCA E O' W JACK OEIP/T r f#ERd HO E
. --t---+~.- _..__r._._.. _ ___~.~i
y II ~
0
D/ -'A T_,S /j' /,/fOHP STEEL FEN £ POST
! - I
/ I
.i
I
@ 9 R P. OP RO P/ E A6SU y/ED / 00 Q'
B7 \p~ 0 j - W
SU/rjA BLE A EA 304 SO rT.
' TN
B6j _
OIN.
~t _t ryrl 1.._-_ _ . 11._..
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k qT/L/7Y FENCE \ t -r- -
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FEN E CiOR AT SW ORN R of S
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and me'tlrbds specified in the! nsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print : TESTS WERE COMPLETED ON:
LAURENCE W. MURPHY f - - e6
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
RI BOX 36A RIVER FALLS, WI 14022 55 - 2445
CST SIGNATURE-
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Teste
DiLHR-SBD-6395 (R. 02/82) -OVER -
r
PAGE OF
rUSS ~ecrton Or ~ ~en S•~s~en-~
Fresh Air Inlels And Observatlon Pipe
Approved Vent Cap
Minimum 12" Above
Final Grode
20- 42" Above Pipe _ 4" Cast Iron
To Final Grade Vent Pipe
Marsh Hay Or Synthetic Covering
Mln. 2" Aggregate
Over Pipe -
Olstrlbutlon - To
Pipe 0 0 0 0 0
6" Aggregate o Perforated Pipe Below
Beneath Plp•
o -Coupling Terminating AI
Bottom Of System
SOIL FILL
DISTRIBUTIO1`3 PIPE APPROVED S4MTHETIC COVER
""MATERIAL- OP, 9" OF STRAW
c,
r OF A6GR EGA1E OR (AARSW HA`J
o0
T y~>' (o' OF -21/2 AGGREGATE
ELEV. OF / r. FEF-T
DIS-I-RIAI,JTIOAI PIPE TU BE AT LEAST ~ INCHES BELOW ORIGINAL GRADE
AQU AT LEAST20 INCHES BUT IJO MORE THAN H2 INCHES BELOW FINAL GRADE
MAXLrLUM ®aPrH of - Im1.9 I~RoM b~~~WAI 6RAD~ WILL BE INCHES
FXcAVAT
MINIMUM ®EPrn OF FACAVA-riow fRoM 01~16INgL (jRaDE WILL BE y INCHES
v
LIC EM SE WRABE R: ~ ~h Gf L%
DATE
PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
.4 '
~I
VENT CAP
4"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
2 JUNCTION BOX MAMHOLE COVER
- 5' FROM DOOR,
12"MIU.
WiNCUW OR FRESH
AIR )UTAKE
GRADE I `i„ MIfJ
I
I` - - I B" MI IJ.
CONDUIT
16"MLN, \
PROVIDE I
I^11 I I AIRTIGHT SEAL I
I I I
APPR.OVEC JOIA!T A I III APPROVED :OINTS
W/C.I. PIPE. I III W/C.I. PIPE
EXTENDIAI(- 3' I II ALARM EXTENDIMC, 3'
ONTO ;,Q; I0 Sr!; B I II ONTO SOLID SOIL
I I
I I ow
C: I I
I
PUMP
I ~ OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SPEC.IFICATIOMS
SEPTIC AND
DOSE TANKS MANUFACTURER: NUMBER OF DOSES: Z PER DAa
TAMK SIZE: RO(I t+ GALLONS DOSE VOLUME
ALARM MANUFACTURER: S C L ~ cTO,- 5',l r't INCLUO!'!L :,;C!;FLOW: GALLONS
MODEL NUMBER: l n/ t/ L CAPACITIES: A= IMCNES OR GALLOWS
SWITCH TtIPE: IZ~ E i,\ C U'): U 5= INCHES OR GALLON5
PUMP MANUFACTURER: 7e.) rL.L~~ C_- ) C- INCHES OR 2-02 'JGALLOUS
MODEL NUMBER: / .X Da INCHES OR 72 GALLONS
SWITCH TYPE: /I { ia' V Y IJOTE: PUMP AND ALARM ARE TO BE
PUMP DISCHARGE KATE y 0 GPM IN5TALLEO ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BC--?WCEA1 PUMP OFF ANO 015TRIBUTIO" PIPE.. 3L FEET
+ MIAIIMUM NETWORK SUPPLY PRESSURE , . , , , , , , B' FEET
+~-5- 2 Z_ FEET OF FORCE MAIN X 2 ' FyOFtFRICTIOU FACTOR.. S~ FEET
' ~t = TOTAL DYNAMIC HEAD FEET
IIJTERMAL QIMEWSIOWS OF TANK LEKI(7-TH 2 21"I;WIDTH -;LIQUID DEPTH .._.LL~.e..
i 2 c="
SIGNED: LICENSE HUMBER: DATE:
-117-
W ~
HE CURVE 161, 163 AND 165 SERIES TOTAL DYNAMIC HEAD/FLOW PER MINUTE
LL EFFLUENT AND DEWATERING
28 ' 9o SERIES 161 163 165
FT. M. Gal. Ltrs. Gal. Ltrs. Gal. Ltrs.
24 eo 5 1.52 106 401 61 231 61 231
MODEL 10 3.05 100 378 61 231 61 231
70 15 4.57 91 344 60 227 60 227
--M ODE 465-- 20
LU 163 20 6.10 82 310 59 223 60 227
= 60 25 7.62 74 280 57 216 59 223
V
g 16 50 30 9.14 65 246 55 206 58 220
a 40 12.19 46 174 46 172 55 206
p 1240 4~ 1 50 15.24 21 80 33 125 51 191
la- 3o OD L 60 18.29 15 57 43 161
0 6 70 21.34 30 114
20 80 24.38 14 53
90 27.43
a
to 100 30.48
Lock Valve: 56' 66' 87'
0
GALLONS 10 20 30 40 50 60 70 80 90 100 110
LITERS 0 80 160 240 320 400 Bn ! -
FLOW PER MINUTE o
411.
Standard all models - Weight 77 lbs. - 20 ft. cord -1h H.P.
0 1'h - 11'b NPT
161 MODELS Control Selection `2-, 15 NPT(oa)
]-BNPT
B
Model Volts-Ph Mode Amps Simplex Duplex
M161 115 1 Auto 14.0 1 or 1 & 9 -
N161 115 1 Non 14.0 2or2&8 3or5&6
D161 230 1 Auto 7.0 1 or 1 & 9 -
E161 230 1 Non 7.0 2or2&8 3or5&6
F161 230 3 Non 3.0 2&4 3&4or5&6
'1-1161 200-208 1 Auto 8.2 1 & 9 -
'1161 200-208 1 Non 8.2 2& 8 3 or 5& 6 k. s
'J161 200-208 Non
3 2.2 2&4 3&4
or 5&6
1BY,.
'G161 460 3 Non 1.5 2&4 3&4or5&6
Standard all models -Weight 77 lbs. - 20 ft. cord -'/2 H.P. ~
163 MODELS Control Selection T
Model Volts Ph Mode Amps Simplex Duplex 6
M163 115 1 Auto 14.0 1 or 1 & 9 -
N163 115 1 Non 14.0 2or2&8 3or5&6--
D163 230 1 Auto 7.0 1 or 1 & 9 -
E163 230 1 Non 7.0 2or2&8 3or5&6
F163 230 3 Non 3.0 2 & 4 3 & 4 or 5 & 6 SELECTION GUIDE
'H163 200-208 1 Auto 8.2 1 & 9 - 1. Integral float operated mechanical switch, no external control required.
1163 200-208 1 Non 8.2 2&8 3 or 5& 6
2. Single piggyback mercury float switch or double piggyback mercury float
'J163 200-20-8-3-1-Non 2.2 2 & 4 3 & 4 or 5 & 6 switch. Refer to FM0477.
'G163 460 3 Non 1.5 2 & 4 3 & 4 or 5 &6 3. Mechanical alternator "M-Pak" 10-0072 or 10-0075.
Standard all models -Weight 82 lbs. - 20 ft. cord - 1 H.P. 4. Combination starter. Refer to FM0514.
5. See FM0712; for correct model of Electrical Alternator, "E-Pak".
165 MODELS Control Selection 6. Mercury sensor float switch 10-0225 used as a control activator, with "E-Pak"
Model Volts-Ph Mode Amps Simplex Duplex alternator, 3 or 4 float system.
D165 230 1 Auto 9.0 1 or 1 & 9 - 7. SIMPLEX CONTROL BOX 10-0050, 115/230V, 1 Ph. max. 2HP use one (1)
E165 230 1 Non 9.0 2 or 2 & 8 3 or 5 & 6 single piggyback wide angle mercury float switch OR two (2) 10-0225 mercury
F165 230 3 Non 6.6 2&4 3 & 4 or 5 & 6 sensor floats for level control.
8. Four (4) hole "J-Pak", junction box, for watertight connection or wired-in
H165 200-208 1 Auto 10.7 1 & 9 - simplex or duplex operation.
'1165 200-208 1 Non 10.7 2 & 8 3 or 5 & 6 9. Two (2) hole "J-Pak", junction box, for watertight connection or splice.
J165 200-208 3 Non 7.0 2 & 4 3 & 4 or 5 & 6 'No Molded Plug
G165 460 3 Non 3.3 2&4 3&4or5&6
For information on additional Zoeller products refer to catalog on Combination Starter, CAUTION
FM0514; Piggyback Mercury Switches, FM0477; Electrical Alternator, FM0486; Mechanical All Installation of controls, protection devices and wiring should be done by a licensed
qualified
Alternator, FM0495; Alarm Package, FM0513: Sump/Sewage Basins, FM0487: and Simplex electrician. All electrical and safety codes should be followed Including the most recent Natkmal
Control Box, FM0732. Electric Code (NEC) and the Occupational Safety and HeaM AC (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
3280 Old Millers Lane Manufacturers of .
O O' Box 16347
Louisville, Kentucky 40216
ZZMZM-ff p
o (502) 778-2731 ` 7,Y&IrY 0LIMPS SNCE lff7 „
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
,IN,DUSTRY, CC DIVISION
LABOR P.O. BOX HU? AN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: OIMUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
sT,1/ Nw 1/ z.-) /T zaN/R 1`i E (or ESN
COUNTY: MAILING ADDRESS:
ST w 5u ol5
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRI I -E DESCRIPTION PERCOLATION TESTS:
Residence 3 N , a 77A~New E] Replace S _ 3- 9(:)
RATING: S= Site suitable for system U= Site unsuitable for system ::!SIM J_)J~PSW (I'Aj
ONVENTIONAL: MOUND: IN-GROUND-PRESSU SYSTEM-IN-FILL OLD ING TANK: RECOMMENDED SYSTEM: (optional)
DsL Esau os®uRE: as ®u rEls u
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: N Floodplain, indicate Floodplain elevation: N • .
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- -r) 6 14 L P C_
B- Z 3 IV A - 10 f/
B-
B- S 1vU`C~ cv~ IC , yV C~ -r ap) S
B- ti U}tiJ U l~J l_
PERCOLATION TESTS
EST DEPTH . WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI0D2 PER10133 PER INCH
P-
P-
P-
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. 1 6kF_t 4 3 v'j P~)4( *l
SYSTEM ELEVATION
F i
.....5`~_~'11
z
F `[fit E N cOI_ OF
E
f ~ ~ Lu QU ~ S '~c
set
3
E
E
u
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): WE03ERER 301L TESTING TESTS WERE COMPLETED ON:
AND 8 _3 - 1913
ADDRESS: DESIGN SERVICE CERTIFICATION NUMBER: PHONE NUMBER (optional):
3Tuo0 S-) b CIS-Vzs-c►~~~
tS(JX /4 4W 1 N. MAIN , CST SIGNAT RE:
RIVER FALLS; WI 54022
715-425-0165
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER
SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet
may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if
appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and yur certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL
AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Standstone
gr - Gravel (under 3") LS - Limestone
's - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Precolation Rate
med s - Medium Sand W - Well
is - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand < - Less Than
'I - Loam Bn - Brown
'sil - Silt Loam BI - Black
si - Slit Gy - Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ - with
sic - Silty Clay fff - few, fine, faint
'c - Clay cc - common, coarse
pt - Peat mm - Many, Medium
m - Muck d - distinct
p - prominent
HWL - High water level,
surface water
Six general soil textures BM - Bench Mark
for liquid waste disposal VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system
and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
SOIL DESCRIPTION FORM
Attach Soii Prot IIL Location Na on a Su grata Sheet)
CL C J`? LINEAR LOADING RATE:
PURPOSE: aiN-Q SuIL b lYU FUZ. SLOPE'
DESCRIPTION BY
C. q(3 CURRENT LAND USE:
pATf.:
COUNTY/STATE: ST- CZ VEGETATIVE COVER: S
LOT DESCRIPTION: .1 -AJA)!1 ;~SEQ,Z- T~K R 7 DRAINAGE CLASS: L~LPL ~~IA~
LOCATION. Ot" 1 - I> R1 L) GALLONS PER S . FT. PER DAY:
PARENT MATERIAL(S1/DEPTH SOIL SERIES
SOIL. UDH.
HORIZON DEPTII MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS Pil -BOUNDARY REMARKS
(BID ist Gr. St. Sh COATINGS
1 0-1 1u`i[Z31Z - s I~ p l ~ v c S
Z7_1$ 10`-123110
3 I$-31 l0`~23/~ - S) ~`~S~k m'F~- 9Lv
►n
3)-46 ►~`1 Cr- ~l/6 yh a~ S o sc~
5 6- IbitZ yt'6 l~ . mQ~S OS _es
~ 49-~ ~ ~o~ 2 1 s 1 s m ~ 1 • w ~ l
u ~ 2
~ 0 lo~c tZ 1 i - 1^ 1 k m v 'F c s
2 110-18 )U 2 3 l 6 ` 1 'S ~k h~ 1- cS
3 _ tnti 2316 - s) 1`~S~k r'( \ S`J`J
310-y Io`-12 /6 `FS-~S o S >ti I cs
S L1y-~ 3 tv~ CL F l FS- S ss v w rn`Fi ?S~`_'3y
'QSrla~ S E~4 ~ ~ T 7 u
i~u wG.3
I b 1 Uyz 31 z s 1 l~ uh 4 s
-1O lb` (1Z 3 16 - S i S 10 1L r►'1 G'v
VA sbn
lbti'R /6 Se~ l'~'SbFc ni iN Po S o~ sl T
S ! 0 V tm . Su 1_ Z
ylj
~ lYU S
10 Al U~ L ~l
(HIT- I- -Tn
1 lv 1 L .
OTHER SITE FEATURES/NOTES: [/1ClCG/1~L
5-3-9D "S )6 fi'n6E Z of Z
LIMITING FACTORS/DEPTH: Signature Date CST N
HORIZON DEP111 MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS P1 11 BOUNDARY REMARKS
in, moist Gr. Sz. Sh COATINGS
OTHER SITE FEATURES/NOTES:
I'N Gt of
Signature Date CST N
LIMITING FACTORS/DEPTH:
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
;INDUSTRY, DIVISION
LABOR ANQ PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707969
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: OWNSHI MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
se NVJ 1 z T z8N R 1-1 E (or ~s - -
COUNTY: MAILING ADDRESS: 1 37 1 g /aIUN
S(, e3;~-ZbC e- 2 ~S S 1~ T~1 !v w sv o15
USE DATES 013SERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFILE DESCRIPTIONS S:
OResidence 3 N New ❑Replace 8 _ 3- 9Q
RATING: S- Site suitable for system U- Site unsuitable for system ck,~ S 1`rt 1--~Y :~S-) M llit-" pSW L>'U 8 b - g
ONVENTI NAL: MOUND: IN-GROUND-PRESSURE: STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
as~u ®sou os~u os®u os~u
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: N • A. Floodplain, indicate Floodplain elevation: N • .
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERV D EST. HIGRTS TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 -r) 6 ~ • N3 ~ 4 L P~vE Z 2
B- "S N A --)IQ) q f~
B- 3 ~O S N.A. 1J1:~yvL ZS
B-
B- S 1vU OAJ Z yV y S77
B- w v ~ U ~ L
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAT MINUTES
NUMBER INCHES' AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD PERIOD PER INCH
P-
P-
P-
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. \Ge C/3
C14~-lZsh vl•.It~M l 1
SYSTEM ELEVATION
{
v
J ~1~ -16.M Or
_ r
m F-
F 1 1
? I ~ i I i k
r
T - , r -r - - } r -
t j ( l
Lu 5
X-T
- - -
- az •31 i
- ft-t :r;z:*-- -:1 T ---t
L 4 = S O ~ - StC , 2-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 : WEGERER 801t TESTING TESTS WERE COMPLETED ON:
AND 8_'3_Q/3
ADDRESS: DESIGN SERVICE CERTIFICATION NUMBER: PHONE NUMBER (optional):
CSTooo S-) b CIS-~zs-v/6S
• • tSUA f4 4Z 1 N. MAIN , CST SIGNAT RE:
RIVER FALLS. WI 54022
715-425-0165
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR•SBD-6395 (R. 10/83) - OVER -
SOIL DESCRIPTION FORM
Attach Sol 1 Prof lu Location Ms On • Su orate sheet!
&LIENT: L. LINE L TNG TE:
PURPOS : SW L V OU SLOP
nesr.Rl_PTtoN BY Ply-~ y*_ L_ - w4~ ASPECT: - -
DATr: G , -a, q q'Q / I CUR ENT LAND US
COUNTY/STAT : S . C-~4 IX LU VEGETATIVE COVER G S
LOT DRAINAGE CLASS: l:A_)
,C.Ik~~ SAC Z7 T~$~ R 17
DESCRIPT ION 5i= lu
LOCATION: Of- l~ v t / UL GALLONS-PER S9. FT. PER DAY:
SOIL SERIES: OIUJ 1)a
PARENT MATERIAL (s)/OEPTII
HORIZON DEPTII MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CPORES ROOTS Pll -BOUNDARY REMARKS
in. Rio st t. Sh S
1 O --1 1km 31 Z - s I P I ~n v F►~ ° S
Z 7 _ 1$ ZO`~1R 3 l6 s; 1 )`FS ~k M'F~-
3 1$-31 tioKCL3/~ - S) I`~Sbk m'Fh 91-v
te- VA
S 6- lb`217- / ma~S -O S -cs -
cS
Z lp-)8 1(3 3 )6 L, 1 S1~k
3 ) - 0 2 3 J - S) 1`Fs ~lrc >n v S I-~•
S U - `t 3 tvk 1 ~s -1 s s S v '~h w m `Fi ~eM Yttd" Sa`= ~3y
"Pp~ S ~4 pc T ..7u'~
I o 10%_tR 31 Z 5 1 , rm U 4 S
3 y/6 - Sl l bn )n U s
--zq-6S t~~tR /6 se~ l~Sb~ »T k w ~ ~L (em of st T
g ! U QD . SU l Z
V IL. S S S F;NUAJN L Q c4-7_ Nt,
5[ C.
1^ 3 - erk
do A) uN L ~l
11v L -
OTHER SITE FEATURES/NOTES:
014 os76 2 Z
nn GI= of
LIMITING FACIORS/DEPTH: Signature Date CST N