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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOtyStilP•. SEC. TN-R_,!~/W
ADDRESS ST. G'ZOIX COUNTY, WISCONSIN
r
SUBDIVISION 1 L r r is LOT SIZE /zl'
a
PLAN VIEW
Distances and dimensions to met:.!: re=j iirements of I•IHR 83
SHOW EVERYTHIPIG WITHIN 100 FEET OF SYSTEM
tyr1~
3
B
5s
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical r°- eren(-,- poi-Ot used
Elevation of vertical reference Proposed slope at site:
SEPTIC TANK: Manufacturer:poiliquid Capacity: G~
G
Number of rings used: Tank natihole cover elevation: ~ / r
yy i
Tank Inlet Elevation: ? JTank Outlet Elevation: /i S 6 /
Number of feet from nearest Rca:G l: Front,~10 Side,(\7).Rear, O~_ _ feet
.From nearest property lik(:.1 Front,oSide,0Rear,Od feet
Number of feet from: well build{r~;:
(Include this information of the aov e plot p1a 2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
PUMP CHAMBER i ,
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
c.
Width: Len$th: Number of Lines:S- j Area Built:
i;
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, Ft. Y
Number of feet from well: , ~ccYY
Number of feet from building:
(Include distances 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 sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector
Dated : Plumber on job ev
Z 1.
License Number: r
3/84:mj
A
jjQooo9)[A
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX ib69 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
V
SW~a~~ ,1 e c..717,T30-R19 State Plan I.D. Number:
El CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Sotiierset Lo lt~
Cty. Rd. V Holding Tank ❑ in-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
I"
Glen Roe ke 1514 150th Ave. Somerset WI 54025 5- - o ic3d
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
I V_ /AJ- u o ~Ii' (D
Name of Plumber MP/MPRSW No.: County: Sanitary Permit Number:
Calvin Powers Jr. 1563 St. Croix 1 135419
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: i,. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
PO W US (1 'L."'v l ~ / (9 0 0 7, 7 6, ~S6 .OYES ❑ NO ❑ YES •EfrNO
BEDDING: VENT DIA.: V T M TL.: HIGH WATER NUMBER OF ROAD: PROPERTY ELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM \ INE: /AIR INLET:
❑ YES 2'KIo f ❑ YES O NEAREST l 0 10 O W/SO
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: POMP CON ROL OPER IQN NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF YE ❑ O NEAREST 101-
SOIL ABSORPTION SYSTEM. Check the soil moistur at the depth f 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:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH
r~ 2 TREES: / M TERIAL: PIT DEPT C-i J1 DIMENSIONS `•'1,~ J I1V- r
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. INLE:; E V PIP : FEET FROM LIt / AIR INLET:
Q-) / Z NEAREST D '&12 Z
l/O
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ 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: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST-►
o L)
e t A I /
U
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATU TITLE:
SBD-6710 (R. 06/88)
4 DIL R SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code Cou
STATE SANITARY PERMIT #
-Aftach complete plans (to the county copy only) for the system, on paper not less than IY5- 17
8tf 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
e. S'w Y. S 4) S T30, N, R f(or) W
PROPERTY OWNER'S MAILING AD ESS LOT # BLOCK #
141 1-5 L,7 0, ' v
CITY, STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
IV
11. TYPE OF BUILDING: (Check one) CITY NEAREST RO(D f or
State Owned VILLAGE : SO'hrt,R I
❑ Public X1 or 2 Fam. Dwelling-# of bedrooms --3- AR L AX NUMBER( S) aaa- ao 4-(~a- 1d
111. BUILDING USE: (If building type is public, check all that apply) 73-41,4
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 120 Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.2 New 2. El Replacement 3. El Replacement of 4.0 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 300 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
S REQUIRED (sq. ft.) PROPOSI (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 42 13 ?/or 3 Feet 9?1 Feet
VII. TANK CAPACITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New Existing Gallons Tanks Concrete struct glass App'
Septic Tank or Holdin Tank Tanks Tanks 4TH O+++ca. t.a
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Nam (Print): Plumber's Sig ture: o Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
vi S o/7
IX. COON /DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved F-1 Owner Given Initial N5 7" d Surcharge Fee) .1
A v rseDetermination J o`~-L~ L2~
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-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 Saritary 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.
SBD-6398 (R.11/88)
' APPLICATION FOR SANITARY PERMIT
STC-100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property 2j LAO & fP&4,r A)Oy Ppi47Xed t:
Location of property SU) 1/4 0*"D 1/4, Section T 30 N-R /9 W
Township
Mailing address ;
c~ )z/ L f 8L
Address of site
~~,1~~~ C~ ~2.s•. Lz_
Subdivision name
Lot number /
Previous owner of property
a
Total size of parcel fo~. 1) 3
Date parcel was created
Are all corners and lot lines identifiable? ✓ Yes No
Is this pro erty being developed; ,f or resale (spec house)? Yes 0
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND 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 references to a Certified Survey Map, the Certified Survey
Map shall also be required.
---------------------------------------------------------7---------------------
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. -5J .7L__; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the Coun)t~y~ Register of Deeds, as Document No. ) .
Signature of Owner Signature of Co-Owner (If Applicable)
I-/9-C~o
Date of Signature Date of Signature
Y.
' 01'
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER X056 Per-
ROUTE/BOX NUMBER 55,5 &Zj4 Ik)46 d)Q • FIRE NO.
CITY/STATE - *
owo6t k- ZIP
PROPERTY LOCATION: c45P_1/4 AAD /4, Section / 7 , TffQ N, R_L? _W,
Town of <=;b'"Ageit.Sfe , St. Croix County,
Subdivision A)A4 , Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior 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 verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED
=~!e~
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DE TP.'ENTOF REPORT ON SOIL BORINGS AND SAtE7Y & bUILUII~
IN TRY, BORINGS AND DIVISI(
LA IR
;
D PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUN I++ELATIONS
N WI 537
• (ILHR 83.090) & Chapter 145)
A 1 T: S C ION: OWNS UNICIPALITY- OT NO.:8LIC NO.: SUBDIVISION NAME:
• '1 4>'/ /L"/"E (o -
COj1 T lylp ^~e MAI f~ADDR SS:
5 G (/j
e 09k en Du p q ,
USE - DATES OBS RVA IONS MADE ~Q A TS
BEDR : COMMERCIAL TION: S
Residence VNew ❑Replace
712-
RATING: S- Site suitable for system U- Site unsuitable for system /.S cs-~ IZ
ONVENTI NAL: MOUND: IN-GROUND-PRESSURE ms EM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional)
S ❑U z ®S DU 2V roszu
If Percolation Tests are NOT required DESIGN RATE:
[Floodplain, any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: AA indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL P H T GROUP DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPT
NUMBER DEPTH IN. ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
,7 q 40p? e
o o^rC ~
B.~ o
B- 96 0 oti~ > 9
B- ? 6- G P -7
B-
u PERCOLATION TESTS
a
TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINU
NUMBER I • ES
AFTER WELLING INTERVAL-MIN. PERIONT P I D PER PER INCH
P. yt
P- G
fia
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 i
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 per
of land slope.
xe SYSTEM ELEVATION y~ .
G.
I ~ Oi src ~
,gyp
/I COW
r I ~O -e c -
I I ,
10-4
_.L.__. -I~,I. i.
i
r
1, the ndersigned, hereby certify that tecte his form were made by mein accord with the procedures and methods specified in the Wiscon
Administra i o e, 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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(option
Q 4/0 Aft ,V- Q~ 4e,41 J; ri e- &-'V 7 ~ts'~'T6<
CST SIGN
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10183) - OVER -
~•ken oV_ -
PAGE OF
C.rvSS S~c~lon o~ ~CI~ Sys en-)
J C~1csG
Froth Alf Inldla And Obbervailan Pipe
( j Approvdd Vent Cop
Mlnlmwn 12- Above
final Grade
20-.2' Above Plpp -4• Coal Iran
To Final 0roda Vent Pipe
Mwsh Her Or SrmM1k Covering
min 2v Aggragalo -
Pipe
0161116 Ilan
Pipe 0 Tao
OtP
6s° Parloroled pipe below
0 Coup
ling Terminating At
Bollom 01 Srblaln
/y
P~p~o)eD ~1~~-~ C~rac•I - ~ .
SOIL FILL
DISTRIBUTIOF.1 PIPE
APPROVED S4MPE.TIC COVER
2" OF G E 1 ~'r c. - "'--MIATERIAI- oR AG R GA E
AGGREGATE
ELEV. OF 941-3FEET~ (aOF2-zl/z
F-3 3
DISTRIBILITION PIPE TU BE AT LEAST n INCHES BELOW ORIGINAL GRADE
AQU
AT LEAST LO INCHES
BUT MO MORE THAN tit IAICHES BELOW FINAL GRADE
MAXIMUM DEPTH OF CXCAVATIDO FXOM oKi&WAL 6KApF. WILL BE grz Z_ INCHES
MINIMUM ®EFrVi OF EACA%IATION f-Ko/A 01 ►10WAL rjR49F_ WILL BE ° 7 INCHES
i
f
I
SIGNED: pzu~~ _0o i I
LICENSE DUMBER: ~S
DATE: 1 1 O
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for ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $185.00 P`Septic $25.00
X Water (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner: vA R(it kl 4- 6k Requested by: fiftaQ ~hsov-N tj Address: "5 ' IS - W Address: Inilt'~ - C' ~'Y1[ ti r
City & State: City & St.jjjjt on ►IAJT
Zip Code: V:~ 5 _ Zip Code • '~~iU l U
Telephone N4: Ih) 5~ 53 Telephone N4: (3) -3
Property address (Fire N° & Street) ~D ) q - PA~ kyu-L
Location: ; , ; , Sec. /W , TAN, R_L~) W, Town of SLn
St. Croix Co., WI. Tax ID 1440 ~ -a yt, - Parcel ID N° ig, 3U. / /r 7 SG
7-v-lou
House color: Realty firm: illo- Lock Box Combo:
Water sample tap location: 5ide_ o~/ bn C.k- whelk-Q&-
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM*
Is the dwelling currently occupied? Yes 0 No ~`C1
If vacant, date last occu 'ed.
Septic system installed by: c.~. T Year 95
Septic tank last serviced by: ti Date:
Previous Owner's Name(s): nth
Have any of the following been observed? h 12
❑Y Slow drainage from house.
❑Y Sewage Back-up into dwelling. p ~'tCQ
OY Sewage discharge to ground surface,
road ditch or body of water.
❑Y ?qN Slow drainage from the dwelling. cry ,\0\,`L
❑Y Foul odors.
7G0~ pEF~G ;
Other comments relative to system operation: CIO eNNG . {
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
i
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
t
IN
1
TO BE COMPLETED BY INSP ION AGENCY
System design &/or permit on file? FIfLes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: M=avity grd ❑At-Grd ❑Mound
Approx. size X ❑Dose ❑Pressurized
Ft .2 =ed ❑Trench ❑Dry Well
❑Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank
Setbacks: ❑Hous ❑Well 06Prop. line ❑Other
Dose tank
Setbacks: ❑Ho ine O er
❑Locking cover ❑Warning label ❑Pump/Floats
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks: ❑House( ❑Wel ❑Prop. line Other
❑Ponding: ~ M1S arge.~. ~9~
General comments: A-) Cal J
INSPECTORS SKETCH OF SYSTEM L
N
Inspector
Title
L SANITARY PERMIT APPLICATION
cou
DILHR In accord with ILHR 83.05, Ws. Adm. Code
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
p e. ScJ 5 f.L S /7T30, IN, R *or) W
PROPERTY OWNER'S MAILING AD ESS LOT # BLOCK #
CITY, STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
11. TYPE OF BUILDING: (Check one) 0 CITY NEAREST RO+ D
VILLAGE : sb tYtRJl~s'
❑ State Owned
FM TOWN QF- C?
❑ Public N1 or 2 Fam. Dwelling-# of bedrooms.=3- ARCELTAXNUMB ER(s) aO ¢_(Jec)_ 100
111. BUILDING USE: (If building type is public, check all that apply) ~7 3 Lf A
1 ❑ Apt/Condo / 7' 7T
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 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line Bit applicable)
A) 1N New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E1 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
1130 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) QELEVATION
910. 3 Feet % Feet
VII. TANK CAPACITY Site Fiber- Plastic Exper.
in gallons Total # of Prefab.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete strutte Con- I Steel glass App
Tanks Tanks
Se tic Tank or Holding Tank Oho O'"'~~" r-o
I El
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Nam (Print): Plumber's Sig ture: o Stamps) MP/MPRSW No.: Business Phone Number:
Gay r 0Y-~ r
Plumber's Address (Street, City, State, Zip Code):
cti S 0/7
IX. COUNTY/DEPARTMENT USE ONLY Issuing Agent Si nature (No Stamps)
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue g
l ~j
Approved ❑ Owner Given initial / ad Surcharge Fee) 4z L'6
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
r-'+- rlnn r`nn.r Tn• Cofnhr R Ph nilriinne Mvicinn Owner Phimtwr
pfaoooo
' r DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
DIVISION
LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
P.O. BOX 7969
State Plan I.D. Number: 3707 SWPAN ,"%ec . 17 J30-R19 (If assigned)
Town of Somerset Lo t--1 ❑ CONVENTIONAL ❑ ALTERATIVE
L J Holding Tank ❑ In-Ground Pressure ❑ Mound
Cty . Rd. V INSPECTION DATE:
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: T7
Glen Roe ke 1514 150th Ave. Somerset ` i REF pT.ELEV. CST REF. PT.ELl/EV.:
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:
At,
MP/MPRSW No.: County: Sanitary Permit Number:
Name of Plumber:
I -A
Calvin Powers Jr. 1563 St. Croix
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
7 5~ PROVIDED: PROVIDED:
~r nc , 0 AYES ❑N0 ❑YES -Q NO
O W PROPERTY WELL BUILDING: VENT TO FRESH
BEDDING: T M~TL.: HIGH WATER NUMBER OF ROAD: /AIR INLET:
ALARM: FEET FROM INE
❑YES O= ❑YES 0 NEAREST (J ISO
DOSING CHAMBER:
MANUFACTURER: BE LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARN G LABEL L CKIDED:OVER PROVIDED: ROV ❑ YES ❑ NO ❑ YES ❑ NO
❑ YES ❑ NO
FRESH
GALLONS PER CYCLE: PUMP CON ROL OPER ION NUMBER OF PROPERTY WELL: BUILDING: A VENT R INLET:
(DIFFERENCE BETWEEN FEET FROM LINE:
PUMP ON AND OFF YE ❑ O NEAREST -I
LENGTH: DIAMETER: MATERIAL AND MARKING:
SOIL ABSORPTION SYSTEM. Check the soil moistur at the depth f plowing FORCE
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: MOTERIAL: INSIDE DIA.: PITS: LIQUID
DEPTH:
BED/TRENCH TREES: / PIT
DIMENSIONS b
WELL: BUILDING: VENT TO FRESH
. LI„_PROPERTY
. / AIR INLET:
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: P O. ISTR NUMBER OF
BELOW PIPES: ABOVE COVER: EL V. INI,FL' E VV ~C4 FEET FROM 60 /-/l 1 i NEAREST W
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
SEEDED: MULCHED:
DEPTH OVER TRENCH/BEO DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED:
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 F-1 NO ❑ YES El NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF FPR OP RTY WELL: BUILDING:
COMMENTS: FEET FROM E:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST--~
1-/~
r„
Retain in county file for audit.
Sketch System on SIGNATU TITLE:
Reverse Side.
SBD-6710 (R. 06/88)
r
V
Form- S T C - 104
AS BUILT SMTITARY SYSTEM REPORT
7
OWNER ` . Ti!w-N SIIIP SEC. _ T N-R_&W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION i..CC LOT SIZE
rLAN VIEW
Distances and dimensions to mec..t ie-piirements of ILHR 83
SHOW EVERYT11I1V, WITHIN 100 FEET OF SYSTEM
R.
:IagmnN asuaoTZ
qo F uo aagmnTd
:aogoadsul
CrC~
:a9anjos3nusH uusTy
• t=
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width:
Len$th: Number of Lines: Area Built: 4
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, 'D ( Ft.
Number of feet from well: h/1,01
Number of feet from building:
(Include distances 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 sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft._
Number of feet from well:
Number of feet from building:
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
}T Abe - ri ST. CROIX COUNTY COURTHOUSE
- 1101 Carmichael Road • Hudson, WI 54016
- _ ` (715) 386-4680
July 14, 1993 O
0
Tracey Jenkinson
600 Second Street
Hudson, WI 54016
Dear Ms. Jenkinson:
An inspection of the septic system on the property of Glen Boepke
and Cynthia Patrick, located at 1514 150th Avenue, Somerset, WI was
conducted on July 14, 1993. At the same time a water sample was
obtained for testing. The results of that testing will be sent to
you as soon as we receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Should you have any questions, please contact this office.
Sincerely,
James Thompson
Assistant Zoning Administrator
mij
COMMERCIAL TESTING LABORATORY, INC.
55f4 Main Street, P.O. Box 526
Colfax, Wisconsin 54730 C3:lr ktj
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST. CROIX COUNTY GOVERNMENT REPORT NO.. 45012/01 PAID 1
CENTER REPORT DATE. 7/19/93
1101 CARMICHAEL ROAD DATE RECEIVED! 7/15/93
HUDSON, WI 54016
ATTN. THOMAS C. NELSON
/
OWNER: (('Len Boepke Cynthia Patrick
LOCATION: 1514 150th Ave., Somerset
COLLECTOR; Jim Thompson
DATE COL LECTF_D. 7-14-93
TIME COL.I_ECTED. 12.15pm
SOURCE OF SAMPLE.' Kitchen faucet
DATE ANAL.YZED.7-15-93
TIME ANALYZED.2.OOpm
COLIFORM,MFCC. 0 /100 ml
INTERPRETATION. Bacteriologically SAFE
NITRATE-N. 3 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, m9/L 1 f
O
CID
LAB TECHNICIAN. Pam Gane
d. WI Approved Lab No. 19
0
_ .P t Means "LESS THAN" Detectable Level Approved by:
® PROFESSIONAL LABORATORY SERVICES SINCE 1952