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HomeMy WebLinkAbout040-1180-10-000 M ~ O 6,3, 0 vq~ Ca a) d a x 60 N orn c ! E cLi a d E 'c CD o. n CL r _ t 3 v° s 3 °3 0 3 (D 0 zo N LL Zo 0 LL c 0.6 LL O o m 3 'vow I c3 vCY)aoi I r~Q i E Q w c° 3 M C7 D ~ I N N Z y Q' y 0) w E E m Z = °o = °o z € v € °p~ ' am am Ce) FN- I I I c 0 o Z a c c u o y o y o a~ N m N a~ N m O G 7 n Q C r- a (D (D a LO 1~ y O O O y N O 00 • (_D L 'w p N N w p C~ O Lam--. w N 4. N O v~ N N C O O` Q z°mz Zza zmz Zz~ N 4i d m CD N C: N i N 75 o CL w a p C r m o c a o _ o o a o p ' H H H ' o FL 3 3 3 m00o aU ILL000 LL LL (L (L (L 0. IL CL •N tv o N o o y O o ~i o ~j w J U > co co CD 0) Z y o 0 0 v p co O O N N - 0 O O O GO O O y O) p 0 N N N O '6 O O -p U) N co N m) y O W y C a v I~> 'O y N Cb N 'O N W ° iE •O d Q U) •C d Q } CA m p o 7 '.4 r> > w LO U) U) U) c 1~1 C 0 'a E cli co CD CD Q ~~r o n j O y r y c r°n cOi a 00 Co O 00 o 00 r L f~ C C y M N 0 y O- I N N N N V 0 O p O C Co y `.2 p O j CO C y v Z D ONi N N t +O+ •O r co C O 0 2 7 2 E t~ Y 7~~ C L ~ O M F- Q N Z H= H W N O Z N Z:5 Z' (n e~ EL € a € a i.; IL L: a m m o d o rr~~• CL 2 an V ~1 A to~a~~'l0U0 l0 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER g-C _e TOWNSHIP. SECTION T ~(G N-R s~ ~.5~ .JJ~ R e~ C r ADDRESS ST. CROIX COUNTY, WISCONSIN 04* SUBDIVISION LOT_~_LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM X ~ ~r e4r: 96.0 ' 6ifacl 0 Qs--, ~ ~~~o ~yx Y6 . 9y.9 Ci'e%+/ o r /tom Q ~~Lc 7~'~C l ~C INDICATE NORTH ARROW BENCHMARK: Elevation and description: P/., Alternate benchmark SEPTIC TANK:Manufacturer: C'e'yet Liquid Cap. Rings used: 3 Manhole cover elev: f4-r,.Final grade elev: Tank inlet elev.: _Tank outlet elev.: 9;,-/,p No. of feet from nearest road:Front , Side , Rear-k~-Ft. > „roe From nearest prop. line:Front , Side Rear Ft. y6' No. of feet from: Well uiel/' , Building: mss- ' (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 1 f 1 PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size 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 yL Number of Lines: Area Built Exist. Grade Elev. J Proposed Final Grade Elev. Fill depth to top of pipe: „3• No. feet from nearest prop. line:Front , Side , RearL/ Ft.__L_o No. feet from well: &t_a No. feet from building s HOLDING TANK 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: Well , building , nearest road Alarm Manufacturer: INSPECTOR: k DATE: PLUMBER ON JOB: , LICENSE NUMBER: jr 6/90:cj 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 zMADISON, WI 53707 State Plan l.D.Number: S W NE 4 i S eC . 36 , T28-R19 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Troy, Lot It LJ Holding Tank ❑ In-Ground Pressure ❑ Mound E F IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION A : D BE (Permanent re eien point) DESCRIBE IF DIFFERENT FROM LA REF. T. ELEV.: CST REF. PT. E Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David Fogerty 3289 St. Croix 128792 SEPTIC TANK/HOLDING TANK: , a :5 .T. •9A*' 4, (AV Z//Y MANUFACTURER: LIQUID CAPACITY: TANKINLETEttV- TANK OUTLE WARNING LABEL LOCKING COVER C ~3 ~0 93.7 PROV DED: PROVIDED: ~ YES ❑ NO ❑ YES BEDDING: xQdl DIA. VW MATL.: HIGH WATER N BER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH C .U, ALARM: FEET FROM LINE: r / AIR INLET- E] YES NO ❑ YES NEAREST 1110- >sv DOSING CHAMBER , TSDf, Lf,_V 9J, 76 MANUFACTURER: BED - LIQUID APA ITY: PUMP MODEL: PUMP/91P+1eN MANUFACTURER: WARNING LABEL LOCKING COVER J) PROVIDED: P OVIDED: jt,' e.~~ DYES ❑ NO s3 ~p ES ❑ NO YES ❑ NO GALLONS PER CYCLE: LIMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY W LL: BUILDING-:.' VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR IN T: i PUMP ON AND OFF E?ff§ ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the s 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 /p~ T d r~ the soil is dry enough to continue.) CONVENTIONAL SYSTEM ,V S ~f ZV = BED/TRENCH WIDTH: L r N OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID 07 ' t TRENCHES: MAT IAL: PIT DEPTH: lil DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PE DISTR. PIPE MATERIAL: O. IS R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIP S: LINE: / AIR INLET: / (off / ~Q~~ , ~(O~ FEET FROM NEAREST S G . ~'3S MOUND SYSTEM: o0 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: BEDITRENCH 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 ] 77 7 PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE ED YES ❑ NO / ❑ YES ED NO NEAREST-► "I 10V ~ owl - ~l Z4 - /14 U X• Sketch System on R in in county file for audit. Reverse Side. SIGNA RE: TITLE: t SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION 7DILHR In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 9 8'/2 x 11 inches in size. la Check if revision to previous application -See reverse side for instructions for completing this application. STATE LAN I.D. NUPBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. Gl/ PROPERTY OWNER PROPERTY LOCATION f Gd '/a '/4, S T,2,- , N, R E (Or P PERTY NER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ' - ] ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER o z 93 -171 II. TYPE OF BUILDING: (Check one) -1 State Owned ❑ CI LL AGE ' NEAREST ROAD ~y ro IfIf 114 U Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms -1-- 'PARCEL T NUM R( III. BUILDING USE: (If building type is public, check all that apply) a~ 0 1 ~Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. R 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 ZrO 0 -2-,3- A9J_ 5- 073 ' 15- !9y Feet P • 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 Se tic Tank or Holding Tank ti 'L _TT F~ I Lift Pump Tank/Si hon Chamber Fa- I El 1:1 1 [:1 FF1 1:1 Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb 's Signature: (No Stamps MR/MPRSW No.: Business Phone Number: 3x I Plumber's Address Str , City, S e, Zip Code . r^ W X. OUN /D ARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued issui g gent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial / Surcharge Fee) Q Q' Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 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 .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. 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. Vl. 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) State of Wisconsin ` Department of Industry, Labor and Humanf Relations PRIVATE SE AGE PLAN APPROVAL SAFETY & BUILDINGS DIVISION Western Regional Office 2226 Rose Street LaCrosse, Wisconsin 54603 DAVID B. FOGERTY PLUMBING Owner, GERALD A. EMHOLTZ DAVID FOGERTY FOGERTY HEIGHTS ROAD ROUTE 2, BOX 282 ROBERTS, WI 54023 RIVER FALLS, WI 54022 RE: Plan Number: S90-40036 Date Approved: September 6, 1990 Gallons Per Day: 750 Date Received: September 4, 1990 Project Name: EMHOLTZ, GERALD - RESIDENCE Location: SW,NE,36,28,17W Town of TROY County: ST CROIX Fees Received: 160.00 Fees Required: 110.00 ( 50.00 Refund forthcoming) The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT PUMPED CONVENTIONAL SYSTEM NOTE: The existing seepage pits are to be abandoned per ILHR 83.03(2). 5 Inquiries concerning this approval may be made by calling( 608) E 785 Sincerely, N «0 DENNIS R. SORENSON Section of Private Sewage Division of Safety and Buildings 4PP027/0009n/10 ~41 cc: GERALD A. EMHOLTZ X Private Sewage Consultant SBD-6423 (R. 08/88) Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54025 (715) 749-3555 FAX 715-749-4000 TO : ATTENTION: FROM: -z ACCT. ~ MESSAGE: ~ 4z- TOTAL 0 OF PAGES SF.NT___~~INCLUDING THIS PAGE. REPLY: T ~ r r t4 ~!L 04 zc r e CD V i t 'C O H f U 0O m~ v7i 44 C NNE M wx ' V1 VNm o ~j ccr W IN' 0 I~ / y ~ it - I ,r , Um O 4 6 s 9 o lft 40(), ^l n w rn 0" MCL 1'• b VNA A •AD~.~A jY % ~ a wZH N~ 17 ` ~ a,cn ~ 1 ~ 'n W A z i - n .n. 400 ij l~ ji. 1 p ' J '-N r-n k IN. rr,y rl ; rah j rr; m r- C7 7 ' v~ • PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 90. 'i"C.I. VENT PIPE 40 WEATHER PROOF APPROVED LOCKING N JUNCTION BOX MANHOLE COVER - ~.5' FRCM DOOR, WINDOW OR FRESH 12"MIU. AIR INTAKE GRADE I y.. MIN. 18" MIN. CONDUIT IB"MIN. 1~11_.F=T PROVIDE I AIRTIGHT SEAL I I I III APFROVEC JOIN!'T A I III APPROVED !01~JT W/C.►. PIPF. DAVE FOGER ~ PG..U#aMING I III W/C.z. PIPE EXTENC!nJ(. 3' Licensed Perk Tester & Plumber I I I ALARM EXTEKIDJUG 3' oK1TO so;.ID s~... #3233 #3289 I I I ONTO SOLID SOIL Forty Heits Road 0 N S 1 T E SEVVi`, L.: S BT LEM ROBER TS. WIS ONSIN 54023 r E' Phone 749-3656 I I OAl _j PUMP OFF t ,,r L.,......3 DEPA t:"J i iy;J RELATIONS CONCRETE BLOCK D1Ui zEGi1 'e' S, :'1"Y A a GUILDINGS IITED ONLY IF TAUK MAKJUFACTURE:R HAS SUCH APPROVAL SEE 01 RESPONDENCE 5PCC.IFICATI0NJS SEPTIC AND DOSE TAQKS MANUFACTURER: G~c'il~t (NUMBER OF DOSES: Z PER DAB TANK GALLOUS, DOSE VOLUME ALARM MANUFACTURER: ` l~i~GLC- IMLLUDING OACKFLOW: GALL NS 1 MODEL IJUMBER: (1 3PL PC%S qE) CAPACITIES: A=~f_IIJCNES OR GALLON5 II. SWITCH TYPE: -3e Cet,c B c "L _INCHES OR GALLONS PUMP MANUFACTURER: '1/ t C _INCHES OR ZF/3 _ GALLONS MODEL NUMBER: S^ D ~ _INCHES OR _L_ GALLONS SWITCH TYPE: IJnT.: ' 7 /S3G MP AMU ALARMRE/T P LIMP BE PUMP DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUIT- ~a~,\y ISO Gat. VERTICAL DIFFERENCE OlL'YWGEN PUMP OFF AKID 015TRIBUTION PIPE.. CIRCUIT- .2 FEET _ A89 3 7 + MIKJIMUM METWORK SUPPLY PRESSURE FEET 1 FEEIT OF FORCE MAIM X %0 FT ful 7- 21o.36Pt ~O FLFRICTIOKI FACTOR.. FEET SOp~ TOTAL DYNAMIC HEAD - -2, 51 FEET wed a~ tr s`u//~ x Y cry( - 1 = s z, /rev yt/ e-la-f, t 4Ctet - INTERKIAL DIMLWSIONZ OF TANK: LENGTH ;WIDTH y'3 ;LIQd6 DEPTH - S7 LICENSE NUMBER: 9-a- E 9 DATE: -117- r I HEAD/ CARICITY CURVE I -TDH VL 40 0,3 30 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DE WATERING 7 SERIES 53-55-57-59 97 137-139 163 165 ! t M T iTRS LTRS LTRS. LTRS LTRS ! 28 7.52 163 248 394 231 231 3 - EFFLUENT AND DEVdATERING -6 " 3.05 ; 129 2t6 300 231 1.231 i 7 4.57 # 72 i i 163 242 227 + 227 227 { 26- - 6.10 _ 104 136 { 223 1 SEWAGE AND DEVdTERING 1-- - . - 7.62 yy °1 30 2t6 -223 1 \ 9.14 i _ 206 - 220 t( 24 1 12.19 i' 172 206 ! f < \ 15-4 - - 125 141 f \ 18.29 ----57 161 22 % 21.34 i 114 ppky 24.38 ' i4 53 ODEL\` MODEL Lock Valve 19 24.5 26' 66' 8T IVi 163 ` 1165 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE f 20 SEWAGE AND DEWATERING \ SERIES 267 268 282 284 293 'I M LTRS LTRS I LTRS LTRS '.L LTRS 1.52 408 386 492 1681 \ - - 3.05 227 273 ! 360 t7.. 598 At- ' f s•• - r+, 3 163 1 16- 4.57 76 238 511 ` F 6.10 _ 3 30 ? 125 ? 401 \ - 77-62 -9 288 1 4 \ 9.14 163 292 10.67 1a6 227 _ . , 4 12.19 46 174 j~ \ ,:c 13.72 38 106 t 12 \ 50 : 15.24 i 45 f A-bJ MODEL ~ ~ Lock Valve: 18' 21' 26' 35' 53' 293 10 MODELS 25 137 139 6 MODEL 284 4' ' - MODEL MODEL i 10` 268 282 - • 2 MODELS~~• vt 53, 55, - f 57,5G MODEL MODEL 1 97 267 :J,.. 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BOX 7969 HUMAN RELATIONS 1 / slVl~ WI 53707 (H63.090) & Chapter 145.045) f LOCATION:.V SECTION: TOWNS HIP/hV6P4W_tPAA_LT_Y_:_ LOT NO.: BLK. NO.: SUBDI ISION NAME- 5W 3 /T,7P N/R l9 E (o rv / - COUNTY-, OWNER'S 8ttYfR`9-HAME: MAi G OD Fft SS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: L'JResidence S S le ❑New Replace O ~f v tv, /fl/"P O RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) PS au o'$ ❑u CAS 0U [IS CCU os 0U _ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: A/ Llf, I'Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 9 ' , y nr< r ' ' 7 'l e-/. r s cv B- 2- r B- -3 p4 fj, e( ~j'i . d ! II B Y o ,gt/ ~0 .3 t3'/ 4 S- "?f - s w /5 i r-r r. ♦ e_'/A' 7' -4- B- 3: y ?7. 9 3 7 s / '/.?,P fl ti z w /7J- 974 ~E6 PERCOLATION TESTS "t./ "Dn/sw~~• r.7' „atS S'B.. sw*, s _ 8. ' n 's w TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 PERIOD PER INCH P- 1 /s~ a he ;1% • P- 'P P- 3 yd < LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori ontal and vertical elevation reference points and sl ow their location on the plot plan. Show the surface elevation at all borings and the direction and percent rf land slope. 3 )YSTEM ELEVATION 9 s! 9 PR Z lygo °s. ow ! t N v s11"C"C_r i ~GSle/7~ Q!t Crd~~flt 7~ ~ FY pct f ~ .<r c c~/~aGl wf~/ / r~iGl'L'+ . ~~1/~y1•, I . ~S' /-1/67/1 Gf/] uf Bf1It `~7~t/H the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with he Y t procedures and methods specified in the Wisconsin Idministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. TAME (print DAVE FoGERTY RiuMaiNa TESTS WERE COMPLETED ON: & Plumber r t6faRNd/ef ~ODRESS: X # 3~ #3 CERTI ICA IONUMBER: JPHONE NUMBER(nptionnq: Fogerty I~ oN 644 Phone 749-3656 CST GNATUR ISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. LHR-SBD-6395 (R. 02/82) - OVER - VI H a 9TC- 105 rr- a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County x d a H OWNER/BUYER M ROUTE/BOX NUMBER Fire Number .CITY/STATE~£~•~(!~0 ZIPJ6 -2, PROPERTY LOCATION: IC, It, Section, T «9 N, Rj_~_W, Town of ~nt4 , St. 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 put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 'j 0 . E I/WE, the undersigned, have read the above requirements and agree y to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Offkee within 30 days of the three year expiration date. SIGNED DATE Z 7Z 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: 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 Location of Property s cv ;4 x'14, Section, T__,~, N-R / Q W Township Mailing Address Address of Site Subdivision Name _S~Yc'f ga J .4 Z Lot Number Previous Owner of Property Total Size of Parcel t (J3~ Date Parcel was Created /9(S Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume ~ejq and Page Number jo as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and pa&e number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION I (We) cehttby that att statement6 on thi,6 bonm ane true to the best ob my (oun) knowledge; that 1 (we) am (au) the owneA (.s) o6 the pnopeh ty dens cA bed in this .inboAmatlon boAm, by vittue ob a wa Aanty deed %ecotded in the Obb.tce ob the County Reg.UsteA ob Deeda" Document No. fo o ; and that I (We) phedentty own the pupozed bite bon the z ewage d izpoz z y.6'em (o,% I (we) have obtained an eabement, to nun with the above de6n bed ptopenty, bon the con3thucti.on ob said .eydtem, and the dame ha6 been duty neconded in the Cbb.ice ob the County Registeh ob Deeda, ad D current No. Lf_,o 1• SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED WARRANTY DEED.-To Husband and Wife as Joint Tenants FORM 399 (Revised) uicn co.. Nuwav cc I~ rr~F J - I. I ~8 0 VOL 4 This Indenture, Made this.-...... . 12th .............---day of ....--.......May--.--•......... in the year of our Lord, one thousand nine hundred and.-...SiXty..f3.x0_ between. Vernon. L... Caxo~. r.m__A.... smusaszz. krta~bacid ..~r~d..? .fe}... 1 III i -------•-............--part.ier3...of the first part, and..-._------ .Gerald_-A.- ___I) holt-z__ana_ Jean-_E,-_F}nholtz,---husband- and_ - _ - " of-- ----River---Fade Wisconsin-..-----........------------------------ . - - - as joint tenants, parties of the second part. Witnesseth, That the said part ieS._.-.of the first part, for and in consideration of the sum of I i One-- Thousand .Five. .Hundred and_NoA-Q to-..then--.------- in hand paid by the said parties of the second part, the receipt whereof is herebv confessed and acknowledged, ha_ve_ -given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by ~ these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate, situated in the County of...... 5t.-.flroix...... I' 1 and State of Wisconsin, to-wit: Lot One (1), Danate Park Subdivision, Town of Troy, St. Croix County, subject to all restrictive covenants of record and farther subject to any and all restrictive covenants 1 attached hereto and incorporated herein by reference. e (The restrictive covenants attached hereto are incorporated herein by reference.) II I I I, I I II' 'together with Al and singular the hereditaments and appurtenances thereunto belonging or in any wise apper- I taining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part.ics-.-of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their heredita- ments and appurtenances. To have and to hold the said premises as above described, with the hereditaments and appurtenances, unto the said parties of the second part, as joint tenants. i~ AS BULL`I' SANITARY SYSTEM REPORT .'OWNED C IV' aS TOWNSHIP Ac SEC.X, T I, R j OW AD- ST_ CROIX C U( WISCOflSIN . I - _ SUBDIVtr Lt) LOT LOT SIZE PLAN VIEW Distances & dimensions to meet: requirements of H62.20 1_~ ~0 rUF~ SHOW EVERYTHING WI'!}1.IN 100 FEET OF SYSTEM IDN/ At. ~,'98p A y / ~kz 1 )e 6s 00 r . r 10 I di atte oath Arrow SCAL>r :-I -i EPTIC TANK(S) ~MFGR. CONCRETE cr' STEEL NO -of rings on cover D p h PUMPING CHAMBER SIZE PUMP MFGR MODEL NO. GALLON er Cycle TRENCHES NO. of wi th length area BED NO. of lines width /S!i length area dept to top o pipe NUMBER OF SEEPAGE PITS Outsiaee diameter total pit area i AGGREGATE L PERK RATI?,ARET REQUIRED AREA AS BUILT 0(2 Disclaither: The.inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that. it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. CREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPF.CTOO DATED (Q'~ PLUMBER ON JO LICENSE N ER p y REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM San.Ltahy Permit /7~ State, Septie,,zg~ NAME-x ^ . .21~~~' /Y Tawnship &.4 St. Cxoix County Location ~ _Sectiove34-Lot # Sub /.vizion SEPTIC TANK / Size gattons Numbers oA eompahtmentA r Distance 6te.om: wett ~ Buitdin9 120 .6.2ope Highwazen PUMPING CHAMBER Size gattons__ ..Pump Manu6aetune& Mode. Number HOLDING TANK JL~~ Size gattons 1Nb 6 Compartments Pumper t System Distance bum: Wett Building 12% stope_ Highwatetc ABSORPTION SITE Bed Ttceneh ~aejv ~Q~*vn 0. gr~•~~ Distance btcom: Wett Building .120 stope Highwaten ABSORPTION SITE DIMENSIONS Width o6 trench ~ y 6t R ¢u nV-d area Co r 5 6t Length o6 each tine 3y 6t Depth ofi tcock below tite f 2 in Numbers o6 ti-nes Depth o6 tcock oven tite °L in Totat .length o6 tines ?,.jo 6t Depth o6 tite be.Cow gkade :d in Distance between tines ~ 6t Stope o6 ttceneh in. pelt 100 bt ➢ Totat absonption vLea 6t Type o6 Coven: Papers oh tsttcaw r" PIT DIMENSIONS Numb en o6 pits 11IDp vet astound pitA ye.6 no Outside diameters 4 t h below in.eet 6t Totat absotcption aAea 6t Area tcequitced 6t INSPECT TITLE APPROVED DATE 19 8 REJECTED DATE 198 REASON FOR REJECTION 4418 REPORT ON INSPECTION OF SANITARY PERMIT # ~-2 916 (1 Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Time of Inspection ame, ress, icense o. OT ns a ing Plumber zzy .3 (3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System ermanen re erence oin escri e: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute horsepower brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO ; 8 HOLDING TANK: Manufacturer o gallons construction ; depth to the cover ft; If septic tank is being used are baffles removed? YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ N0; Wired? ❑ YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAG TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% failing away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095(N.05/801 Signature of Inspector: r 4 M un State Permit # O pL B 6 7 State and ty Permit Appli lication County Perini # - 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: bAQ I b 4 N~ B. LOCATION: Y E Y4, Section ,y k., TX N, R__R E (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township y- _qI~ ~.V- C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) _ *Variance Single family NZ Duplex No. of Bedrooms 13 No. of Persons D. TYPE OF APPLIANCES: Dishwasher i YES NO Food Waste Grinder~YES_NO * of Bathrooms Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation ~N~ Addition Replacement- Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)q3) 4/ Total Absorb Area sq. ft. Newer Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _ Seepage Bed: Length _59' Width Depth Tile Depth No. of Lines y •'r Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land r Distance from critical slope 1, 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 Tes NAME C ~F C.S.T. # SS J 61 b and other information obtained from C~a N) (owner/builder). n _ Plumber's Signatur k1P/MPRSW# Phone #7/. yD'J';~(1t/ Plumber's Address ' PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.2 GIw4 A!I- w 11J _ D. r"c-S t e l r I Do Not Write in Space Below //FOR DEPARTMENT USE ONLY U Date of Application c Fees Paid: State County ~z) Date Permit Issued/Rejeeted (date) Issuing Agent Name Inspection Wes~No Valid# Date Recd 1. county (white 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 SH-115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS ~ LOCATION: , Section N.., TiN, R A E (or)e Township or Municipality. WIN., /4 n Lot No. --L-, Block No. DjA tJJV 6 PqkK- County Owner's Name: !i. A ~ n AK% Subdivision Name r-- m r)tj _ c~ Mailing Address: 19 i~ LL S TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW AD ITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET/ SOI L /-TYPE /LG bT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P-1 ARIAIL5 ~94~ C) !4y/6 r~yl(_.. P~,~~ OIL, a 0 YL4 9 Yef' 3///"'QQQ v C~ V / v SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTI IGHEST (DEPTH TO BEDROCK IF OBSERVED) q No tj - J"j 17",L 5 1 "S L. 4 r~ B / _ it ' ,n xj~mg L . F 0 PLAN VIEW (Locate perco lat io n tests,so i I bore holes and suitable soil areas.) Y Indicate on the plan the location and square feet of uit3le are Indicate number of square feet of absorption area needed for building type and occupancy. 5 Indicate scale or distances. Give horizontal and vertical reference point icate slope. ~p I ~ N ~f 1 3q 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 location of test holes are correct to the best of my knowledge and b ief. Name (print) Ce of cation N, + r Address ~ Name of installer if known e CST Signature COPT( A -LOCAL AUTHORITY p ~ 1 i ' , A~ 1~.`1 i ..t ' i - - ~ ~ ~ I ~ w~, ~ s._ _ _ ~ ~ ~ _ - w L _ _ ~ _ "I ~ ~ - ~ .r ~ - _ a - ! ~ - ~ t . SSS.,i~y' 1 ' Y i. ~ , O' 1 V' ` t ~ T ~ ~