HomeMy WebLinkAbout034-1056-60-000
-0 C)
a' o
Z~l o O 6°y
o x
0. c
o I
o y I
o I I _
N I
M m N
ti 70
~ C
N
C
n E !
N T
~ N
C
F. C •N ~
fa ~
C Z N c Co
L fa N O 'y
O
=o mNE
oda~
N "O d
C
C
O C')
~ I N
E
E L
z
H a m
N ~
0
O z 2 ° v
c
aUi Z d ° c
!p t- r ~ N Z
c E -a
Cl)
N ~
0) CD tbw~p I a,
.
~a N a
pawl r- r' o
CL p N
Q z° U) Z h--
0
N
a,
N
~ _ R a7
d
N 6 to w C
~ o c a
° to w
X000 n Z
•N Q a a a
a
CL
Y O O
7 O N
N U 0) 0) o
Z
_ Cl)
Q N N _ 3 ~.J E N
.Q M
G Q LL
I, O
O d Q Z) Rt
A
0 C',
C
> V! O V E
Q) 0
O E O CO F- 2 N C C
U LL O0 (D
r M O E= 'O N N
a)
4* 00
C N Lo N O Z .O C N
10 It 04 00 2
• 7'a M a N co O N E O U
y„ O N (n d O - F- Z Cn
O ~ I
w
- al
a
it a ` a w
• a m ar
rr`iwV c c
_1 A U a 0
w
• i
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 Plan I.D. Number:
E z , Ek , SW 4 ,Sec . 25 , T2 9 -R15 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
~jjffl of Springfield E] Holding Tank ❑ In-Ground Pressure ❑ Mound
Ave.
NAME OF PERMIT HOLDER: 7,Rt.l. ESS OF PERMIT HOLDER: INSPECTION DATE:
Gustave Platson Knapp. WI 54749
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
pale Hudson 6629 St. Croix 128858
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST 00-
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: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPES ACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: I ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
`r ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
FKEPER R TRENCH /BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDEDSEEDED: MULCHED:
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
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
El YES ❑ NO ❑ YES El NO NEAREST-♦
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
IZUILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
~ if r-0
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /C (y
8% X 11 inches in size. Check if nevi on 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
~ s a, S Zj~ TZ9, N, R I (or W
a Q sa j:kjz tI
PROPERTY OWNER'S MAILING ADDRESS LOT #~4 BLOCK #
PHONE NUMBER SUBDIVISION NAME OR CSM NUMBEI33
CITY, STATE / ZIP CODE 1( 71S -21~5 A~~
-,<n a PD 16-V II. E OF BUILDING: Check one) CITY NEAREST ROAD
( State Owned V
ILLAGE' r,'n A 70 72t e ,
4OWN OF: 'f
Public JX 1 or 2 Fam. Dwelling- # of bedrooms PA EL TAX UMB ( )
❑
III. 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) ~~tt
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. Z 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 0 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.) PROPO (sq. ft.) (Gals/day/sq. ft.) (Min..//inch) //A E TION
NX Al, Feet W Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
El El 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 Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
.57
7~ ~R~olu~ J~✓I ~i~, S'h
IX. LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Sigture (No S mps
Approved El owner Given Initial Surcharge Fee) ~4
Adverse Determination J
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
t I
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
sub"tted 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 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.
ll. 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)
1 ,
" 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 CL-7- ~1/G ~r
Location of property Z W4 Gf~ 1/4, Section l , T l N-R W
Township L2
Mailing address
Address of site
Subdivision name
Lot number Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes ~No
Volume 7? 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 warrant deed recorded in the Office of
the County Register of Deeds as Document No.~/ 7,;;'1-9 ; 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 t 4e County Register of Deeds, as Document No.
C
ignature of owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
- _
µ -
Zk'
1
(F ` 1
x K r +r
~ It r'p
46
7.10
2
F
s L 1
sx' ~
Ec~ ~ • r ` t
• z
H
9
S T C'- 105 r
H
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
d
a
OWNER/BUYER ✓P
ROUTE/BOX NUMBER, Fire Number
CITY/STATE!%~t~ 7.IP
PROPERTY LOCATION: _ fg,, 51-d ' Section T ~ N, R. A5' W,
Town of~,L St. Croix County,
Subdivision A Lot number
1
Improper use and 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 pum tr. What you put into i
the system can affect the function of ttie 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
0
• E
I/WE; the undersigned, have read the above requirements and agree z
cn
to m;intain,.the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- It
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.
SIGNEDs
DATE
St. Croix County Zoning Office
P.O. Box. 98•
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign,.date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: S SECTION: TOWNSHIP/MU CIPALI Y. OT NO.:BLK NO.: SUBDIVI I N NAME:
) in Al,
Lpf- T N R 5H ' (or lel
CODUNT/Y~: OWNER'S BUYER'S NAME: AI}IN ADDRESS:
USE DATES OBSERVATIONS MADE
Residence NO. B DBMS.: COMMERCIAL DES RIPTIO ❑New ❑Replace PROFILE DESCRIPTIONS: PERCO
A14 7? S S:
I 9
eecorlafC
RATING: S- Site suitable for system U- Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optiona1)
S DU WFUJI S DU S DU El S U 0 S MU e
If Percolation Tests are NOT required DESIGN RATE: If an
r any portion of the tested area is in the n/
under s.H63.09(5)(b), indicat ,/GV/ e: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH^ ELEVATION OBSERVED ES IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B_ A14 Al~&, q, 17 /,/,7 3 L5 San'4 /-:U/Coarse -ra 4al t
B-
B_
B-
B-
B-
PERCOLATION TESTS
TEST DEPTHWATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES'. AFTER SWELLING INTERVAL-MIN. PERIOD 1 P RI D PER INCH
P-
p_
P-
P-1 71
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 777
e; a 91,117
i
TN
it ~ ~ ' i ~ I i I ! I
I
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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
2z~ 7 S1l~ 7~ - Gay -S
G o~
CST NATURE: /
co.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
r ~
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: braw•ing to scale is preferred: A
separate sheet may be used if desired;
Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
,.9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, 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 your 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 - Sandstone
gr - Gravel (under 3") LS - Limestone
*s - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Percolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is - Loamy Sand > - Greater Than
*sl - Sandy Loam < - Less Than
*I - Loam Bn - Brown
*sil - Silt Loam BI - Black
si - Silt 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, line, faint
*c - Clay cc - common, coarse
pt - Peat mm - Many, medium
m - Muck d - distinct
p - prominent
HWL - High water level,
* Six general soil textures surface water
for liquid waste disposal BM - Bench Mark
VRP - Vertical Reference Point
I
I
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.
i
Owner':
Z ~ GuS~a vE. ~/4fSo►~
P,-,p ose~
2 Rt. l
I I KnaPP,
l B,R,
1 r
G
I
E
se p~'i G
io
~rr~,,~ell a
p t3~
1
a
3 Sec. zs
0
` ~Z ~z swi 79N ~i~~
v r, ✓1C~ P,
I S ~ -~;'e ~C'1 ! urn S~
Drawn ►3y
I /}'J P GGL9
Vo" ScQle
C s~ 3~/3
e ,
I I ® I Gustave t~/otson
z y Pao osed
JPt.
l r
i
a
e
I r
1 ll•
Sep Ci
io
l err „~e~i e
I d a1
l
a
3 sec. 25
I I s: t
0
~ EZ ez scv~ 79N ~
I s r;n h ;eI ro isXf
P 9
i
J ro wn 13y
~
,a& e,
/j"IPGGL9
/ y0~ Scale
C s~ 3~/3
70 t~ 4v-e