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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
4
OWNER TOWNSHIP
SECTION_,2~E_T~N_R
ADDRESS- ,,2 ST. CROIX COUNTI, WISCONSIN
SUBDIVISION- LOT-14-LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f
Q,
6 6 ~ 1~~5
INDICATE NORTH ARROW
BENCHMARK: Elevation and description:_d '
Alternate benchmark -00
SEPTIC TANK: Manufacturer: -
Liquid Cap.
Rings used:lLojnhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front /Side , Rear Ft.
From nearest prop. line:Front , Side X, Rear Ft. 8 l
No. of feet from: Well Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump/Siphon Manufact.: Pump Size
Pump Model:
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump Off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front-, Side_, Rear Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: Length Number of Lines: Area Built .-'L2C-
Exist. Grade Elev. Proposed Final Grade Elev.-
Fill depth to top of pipe: L~ -T
No. feet from nearest prop. line:Front , Side_,,,,, Rear Ft.),5
No. feet from well: No. feet from building ::~2o
9e w- dl ^ O
o-3-
HOLDING TANK f
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Wellbuilding-, nearest road
Alarm Manufacturer:
INSPECTOR:
c
DATE: PLUMBER ON JOB:
LICENSE NUMBER:.
6/90:cj
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
NB, IV)~~SONnWI 553707
1 18W State Plan I.D. Number:
N LL I ® CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town o6 Sian Phcwr.%e
Lot 16 No&thwood ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound C /0
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION A :
Glen NeAby Rt. 2; B234C _
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: ST REF. PT. E V.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
B non BiAd Jn. 3318 St. C&Oix 128750
SEPTIC TANK/
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COV R
_ PROVIDED: PROVIDED: ~
G~ 19 YES ❑ NO ❑ YES NO
BEDDING: VEMfiDIA.: VEN~MATL • n HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENTT FRESH
C•U• ALARM: rFE E T FROM LINEAIR INLET❑ YES NO ❑ YES NO EAREST
InA
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: NUM PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF) I [__1 YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: J-P*;~LAND~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. ~ 0.~42 Q-f S
BED/TRENCH WIDTH: L H: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
s TRENCHES: MATER L: T DEPTH:
DIMENSIONS S3 T
GRAVEL DEPTH FILL DEPT DISTR. PIPE DISTR. PIPE 11 DISTR. PIPE MATERIAL„ N ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPE S: ABOVE C 9 ELEV. INLET: ELEV. END: -lF./- U~ PIPES: FEET FROM LINE: / i AIR INLET:
ef(J - I . ~ }7 ' - -a7 NEAREST -411- 16 _ aD
MOUND SYSTEM: rZ",J 6-13
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 THS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES: \
❑ YES ❑ NO ❑ YES ❑ NO T ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: VEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. R. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: IA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: ICAL LIFT CORRESPONDS TO
INFORMATION APP PLANS
❑ YES ❑ NO ❑ NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BU
ILDING:
FEET FROM 1 LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
-t T
lCl ( C ` c
~ ~ ('-CZ..`~.,/ GZ~~ ~~,e".~l"1 ~ ~~il-.•~. etl~~/•
"e -'I N C_k4r
ain in county file for audit.
Sketch System on
Reverse Side. SIGNAT RE: TITLE: _-67
SBD-6710 (R. 06/88) Zoning Adm~ rws catO&
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
G
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than /12 7J-0
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 OWNE PROPERTY LOCATION
G eh %sAya,S T N,R E(o
PROPERTY OWNER'S MAILING ADDR LOT # BLOCK
0& 'R P G
CITY, STATE, ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
c~1~ r O o? GS6/ G, I o 0 oeoo,
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) State Owned VILLAGE
OF:
❑ Public S 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUM )
!lc57-gyp-Od
111. BUILDING USE: (If building type is public, check all that apply) C-1a
1 ❑ Apt/Condo (o
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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.E1 New 2. 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
~o i 41 le - G Y C- 9CJ• Feet eet
VII. TANK CAPACITY 11 - Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank Azov IR I FT- F] F]
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:
Plumb s Address (Street, City, State, Zip Code):
Gam/ 00
//Z~ + 9~; ; F'o17
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps)
Surcharge Fee)
)IN I Approved ❑ Owner Given Initial QO Q _ a? -
Adverse Determinationi 146 -
/ o
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 maintaMed. 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 ohsite 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.
li. 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 ail
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 volurne; 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 1,15jorm; and F) all sizing informatioric,,
- - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies.coilected 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 644,9 Location of Property _AJ2: Sectiorw2;:2' , T N W
Township S ~r ~i^a ire ,~v7` y f~wamc/
Mailing Address z&,Z a 3~~ ~ CcJ chn-,ovr I ^ 7
Subdivision Name ~/0 y a0l,_ZV,
Lot Number
Previous Owner of Property h rsy
Total Size of Parcel a 7o i 20 d~
Date Parcel was Created 01~
Are all corners and lot lines identifiable? ~ e Yea No
Is this property being developed for resale (spec house) ? Yee No
Volume O •r~ and Page Number JF as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3.• Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) eeAti.6y that att dtatemente on thiA 6onm ahe tAue to the beet o6 my (oun)
knowte.dge; that 1 (we) am (a4e) the owner (b) o6 the phopeh ty deb cA bed in th,id
.in6oAmattion 6onm, by viAtue o6 a wak.a ty deed aeeo,%de in the 066.iee o6 the
County RegiAteK o6 Deeds a6 Document No. S`0 ; and that I (we)
phebent.ty own the p!copoeed 4ite bon the sewage pod dystem (on I (we) have
obtained an eademen t, to Aun with the above de,6 cA ibed pnopen ty, 6oh the
condt4ucti.on o6 ea.id dydtem, and the same had been -duty neconded in the 066.ice
o6 the County Reg,idten. o6 Deed6, a6 Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
~:d~•'• t Rte; •.,p.~y, r.`. k aT' `C ~ ,
•
T. rr. i t . r, s r or
'1~ '~:ife+!~,.~En, •.zL ;Yi'~ ..~t . ry ;.i'.k~" . J?Sli
r ~!t:, ~t'~.r •t•'' {;,++yC. ~ .'"r'rp~k. ',,,CCCT "''°'c'w,"
y.
° Yes . ~•zr M yg
777
e~r,.',y t1."asN ~
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
9
H
OWNER/BUYER
G, ~r
s~~~
ROUTE/BOX NUMBER p? o- 3-1 G Fire Number
.CITY/STATE ~~✓/~fGl~~lo~rG! Gl/i ` ~Yn/~ ZIP
PROPERTY LOCATION: ~'k~~ tt1L, Sectio~ T~/ N, RW,
Town of ~/a -AASt. Croix County,
Subdivision Lot number.
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 pumper. What you pdt 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. Ho
E
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ro
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 A%e~
DATE St. Croix County Zoning Office
P.O. Box 981
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF SAFETY & BUILDINGS
-INDUSTRY, REPORT ON SOIL BORINGS AND DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707969
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: HI MUNICIPAI_ITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
!1'~ /T N/R,/ E ( ar _ !tea
'COUNT'?: MAILING ADDRESS:
r
r.6r f~ - ~i~ o Gc1 o/
1, 1irv x A L102
USE DATES OBSERVATIONS MADE 6
NO. BEDRMS.: COMMERCIAL DESCRIPTION: A STS:
Residence ❑ New Replace
I~-
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: IMOUND: cIN-GROUND•PRESSURE: SYSTEMM-IN-FILL OLDIING TANK: RECOMMENDED SYSTEM: (optional)
S ~u J ou S E1U EIS C9U EIS [A
'jV
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: Floodplain, indicate Floodplain
elevation: lye
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST EST TO BEDROCK IF OBSERVED (SEE AABBRV. ON BACK.)
B- 0/4,10
B-
B-
B-
PERCOLATION TESTS
H TEST DEPTH ATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES FTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D 2 PERIOD 3 PER INCH
P_ Oi nng v CO
P- O'
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.
SYSTEM ELEVATION. 5-
4T-
E
IN
3
E ~
3
rr t/!
A7
I, the undersigned, hereb 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):
'
CST IG T E:
c
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10183) - OVER - J
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
fs - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand - Less Than
'I - Loam Bn - Brown
'sit - Silt Loam 61 - 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
PLOT PLAN
W, -PROJECT e r ADDRESS
Jf/~ 1 /4~/sr11 /4/S~,,Z/T~ N/R/J!5 l TOWN
i* r (r r COUNTY,57, 6ne,,x
MPRS Byron Bird Jr. 3318 DATE 9'a
BEDROOM CLASS PERC__~ CONVENTIONAL,2jIWGROUND PRESSURE
CONVENTIONAL LIFT MOUND_ HOLDING TANK
SEPTIC TANK SIZEL, ras~FT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE 3 BED SIZE -
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark s o- y
* H.R.P.
❑ Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING
2"
12" 3' 4 6' D 3' 3' O 3'
60 Sewer Rock
12' 18'
0
iova _ ~w~ /mod /3~~ St 3
10
v~ ~ao~
G
1
.
AS BUILT SANITARY SYSTEM REPORT
;ER , TOWNSHIP 5 'SEC.NSIN. TN, R_W
ADDRESS , ST. CROIX CGUNTY, WISCO
'DIVISION LOT LOT SIZE
PLAN VIEW
Distances b dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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AAAow
>~TIC TANK(S)MFGR Indicate Nanth
.A~_°~ ! 2X%,rx-2 CONCREETE_) STEEL Scate
NO. of rings on cover / Depth DRY WELL
7'N_-NCHES NO. of width length area i
no. of lines ~r width_~ length S 1' area•~~
depth to top of pipe
3REGATE [;/r~°, 5 rc'~1~=
RATE /~I•, AREA REQUIRED Lj<
AREA AS BUILT
.glaimer: The inspection of this system by St. Croix County does not imply complete
._fpliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
:tem operation. However, if failure is noted the County will make every effort to
-.:ermine cause of failure.
ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTE!
`'INSPECTOR
DATED PLU:iBER ON JOB J ,~5
LICENSE NUMBER ~S 4 _
E H' 1-1 Rev_ 9/78
4 REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION:'/4, 4&%, Sectiorl )Q T',3j_N,RJ,9_q (or) W. Township or Municipality-
Lot No. 11(i Block No. County S T PAi
u6aiwsion ame
Owner's/Buyers Name:- I
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT -ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS 7 PERCOLATION TESTS
SOIL MAP SHEET f I NAME OF SOIL MAP UNIT4/RRA& Lce4 .5.4 ~
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- SINCE HOLE HOLE AFTE INTERVAL
INCHES THICKNESS IN INCHES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
BER 1ST WETTED SWELLING IN MINUTES
P- i I 416AI IS
P- J 1
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B-
B-96 4S ?,K
B- 3 -3 9
B- c
B- 7 - - S
B- >
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the 19cation and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy - Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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I, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
Certification No.~.~
Name (print)
Address
.Name of installer if known
Local Authority CST Signature
Copy A -Local'
s.
Y ~
z• • REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM
San.itany Penm.it
State SPpt.ic_OO7 7
NAME rownbhip A&' I)q,4 ZAA& ~ S$. Cno.ix County
Location,&,60-1,.yV?Z) Section 22,
SEPTIC TANK
Size _gattons. Number ob Compantmentz ! I
Distance Fnom: Wett 13-79 6t. 120 on greaten Atope
Bu.itd.ing 6t. Wettands
H.ighwaten
DISPOSAL SYSTEM
Distance Fnom: We.E!t6t. 12% on greaten stope - 6t.
. Bui.2ding~~6t. Wettands Ft.
.
• tf.ighwaten 6t.
FIELD DIMENSIONS: -
Width o6 tnench~6t. Depth ob rock below t.ite-l-Z.-in.
Length o6 each tine 6t. Depth o6 rock oven t.ite Z .in.
Numbers, o6 tin e.6 Depth o6 t.ite below gradeZ~ .in.
Totat .length o6 tines 6t. Stope o6 trench ~ .in pen 100 6t.
Distance between tines 6t. Depth to bednocft6t.
Totat abzonbt.ion atcea 6t2 Depth to gnoundwaten fit.
Requined area 6t2 Type o6 Coven: aeti n Straw
-~p
PIT DIMENSIONS:
Numb en o6 pits Gnavet around p.itb ye.a no
Outside d.iameten b Depth below .inlet
2
Totat absonbtio nea 6t A
Area quined bt2
INSPECTED BY LE `
-iL
APPROVED -,DATE --/D 19 7~
REJECTED DATE 197.
pp-
State and County State Permit #
PLB6T Permit Application County Per i#-
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: Y4 A6W Section T_3j_ N, R J4 q (or) W Lot# City _
Subdivision Name, nearest road, lake or landmark Blk# Village
Township SrAvf
C. TYPE O OCC PANCY: Commercial *Industrial *Other (specify) *Variance
Single family X Duplex No. of Bedrooms No. of Persons_
D. TYPE OF APPLIANCES: Dishwasher _K YES NO Food Waste Grinder-YES NO # of Bathrooms
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY Jbp Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete X
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) L 2) / 3) Total Absorb Area sq. ft.
New X- Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length 5ZZLWidth a' Depth ~ Tile Depth No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land IF Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME - C.S.T. # ~S"„~..31 and other information
obtained from (owner/builder).
Plumber's Signature P/MPRSW# Phone
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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ion
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Do Not Write in Space Below FOR DEPARTMENT USE ONLY 0~0 30
Date of Application 3 0 Fees Paid: State 0 e Q 0 Co my Date
Permit Issued/mod (date) -Issuing Agent Name C
N0 Valid# Date Recd
Inspection Yes
1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76