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'DEPARIVENT OF INDUT TRY, INSPECTION REPORT FOR SA Y & 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:
Stnl 4 , jvra ,Sec . 36 , T28-R19 ~Q( CONVENTIONAL ❑ ALTERATIVE (it assigned)
Town of Troy j"` ❑ Mound
❑ Holding Tank ❑ In-Ground Pressure W10 0, 4
ON A
A E O MI LDER: ADDRESS OF PERMIT HOLDER: IN;;CT,
,4 -7
S4
1806 Co. Rd. MI M River Falls WI 54 71101,5)0 1?~
BE C A K ( ermanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELE ST REF. PT. ELEV.'
8 'u
~a c3y uSt' S %c~/n mac! ~'I C Gsr~h e/ O ~u C~ . = ~b.00 , cJ?~ - 2(J
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: ce'r r
3231 St. Croix 128700
SEPTIC TANK/HOLDING TANK: 3'-2~E~
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANqLETELEV-.-I WARNING LABEL LOCKING COVEPROVIDEDPROVDEDn f ' ~ 57 YES ❑ NO ❑ YES NO
BEDDING: U&W DIA. V MATL.. HIGH WATER UMBER OF ROAD: T WE : BUILDING: VENT TO FRESH
C, 0ALARM: FEET FRAM q / AIR IN T,
❑ YES NO ❑ YES NO NEAREST
DOSING CHAMBER: //,S', j a 1e. - =
MANUFACTURER: BEDDING LIQUID CAPACITY: PUMP MODEL: PUMP/SIP4i9N MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
i1/' C ~ ❑ YES I2J NO -,75-0 ' S3 0oe_C6e e- YES ❑ NO YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WEL BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: p~ , AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST >a >Sa o?V
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 7,
BED/TRENCH WIDTH: L NO. OF DISTR. PIPE SPACING: :NO;. EINSIDE DIA.: # PITS: LIQUID
i TRENCHES: / i PIT DEPTH:
DIMENSIONS 6 GRAVEL DEPTH FILL DEPTH DISTR. IDISTR. PIPE MATERIAL: . PNUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE C/OV ERR: ELEV. INLET ELEV. END: PIPES: FEET FROM ' rn AI I LET:
L 3F - 70~ / ei-a. RESTT LINE: Jv _90 '6 MOUND SYSTEM: 6.1 ' r/C-
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 [:1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
E] YES [__1 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:
^CQMMPNTS: FEET FROM LINE:
J cue d _A % ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
~'/~fp/~ ~,/J '-P ~''~-c.L~P 0rfu-r!_~i._. n.i,..~C1UZor' k/°IISC' Q%~1 rJ7
Ret in in county file for audit.
Sketch System on
Reverse Side. SIGNA RE: TITLE: {
SBD-6710 (R. 06/88) T
SANIT
ARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code
,,.e,.,..,..,.~..~
DO
Now
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than / 0
8% x 11 inches in size. ❑ C4 if revis Itprevious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPSATY O NER PROPERTY LOCATION
'5'cJ %a,S ~o T~O,N,R ~Q E(o
PROPE~ OWNER'S MAILING ADD LOT # BLOCK #
CI STATE ZIP ODE PHONE NUMBER SUBDIVISION NAME OPZ UMBER
I k, 1~o if- I/ - /c V 6
[3 SI
IL TYPE OF BUILDING: (Check one) CITY NEARE OAD
❑ State Owned ❑ VILLAGE
OF:
NUMBER G / _
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms AR EL AX
_'t 7
III. BUILDING USE: (If building type is public, check all that apply) 101
1 El Apt/Condo (J
20 Assembly Hall 6 El Medical Facility/Nursing Home 10 El 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 1:1 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. ❑ New 2. 0 Replacement 3. ❑ Replacement of 4.0 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 I Pressurized Distribution Experimental Other
11 Seepage Bed 1-7 /KS 2 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
130 Seepage Pit Pressure 43 El 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
_/~/V a 0 < /e~ / t D Feet c 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
G10Gv~
Septic Tank or Holdin Tank w v
M El I El
S
I A I *;/~zk, en r&-e4 F] FIL4 -1
Lift Pump Tank/Si hon Chamber ~C
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb is Name (Print): Plumb ignature: (No Stamps) MP/MPRSW No.: Business Phone Number:
P mb s ddress (St set, City, S e, Zip Code): l 7
~ be"
IX. CO_JM TY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater M Issued Issuing ent Signature No Stam
Approved ❑ Owner Given initial Surcharge Fee)
/ vs-_ G
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 a 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.
II. Type of building being served. Check only am 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; (Jose 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.
I
I
SBD-6398 (R.11/88)
,R
e.
. APPLICATION FOR SANITARY PERMIT
8TC-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 petmit issuance. -Should this development be intended got teaale by
owner/conttactot,(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 ptoperty~/4 /4, section T ~d .N-R~Y
Township
Mailing address , 6
Address of site 4
Subdivision name B b~ C
Lot number
previous owner of property
Total else of parcel it
Date parcel was created
Are all cotnets and lot lines identifiable? Yes 0
19 this property being developed lot teaale ('spec house)? as 0
Vol""nd Page Number 4~YW as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWINCs
A WARRANTY DRRD which Includes a DOCUMENT NVMBRR, VOLUMS AND PACs; NUMSIMe and
the BRAG of THE RRGISTRR OP DRRDB. In addition, a ceztified survey, if
available, would be helpful so as to avoid delays of the reviewing process. It
the deed description references to a Ceitilled Survey Map, the Cattifled Survey
Map shall also be requited.
PROPRRTY OWNER CERTIFICATION
i(Ve) certify that all statements on this form are true to the best of my tout)
knovledgel that I (we) am (ate) the owner(s) of the property described In
this information form, by virtue of a warrant d--SSed recorded In the Office of
the County Register of Deeds as Document No. and that 1 two)
Presently own the proposed site for the sewage disposal system tot I (we) have
obtained an easement, to run with the above described ptoperty, tot the
construction of sold system, and the same has been dui recorded In the office
e hs Co ty R Istsc of Deeds, as Document No. 8~.~
;PAO
S gns ure of owner Bignatute of co-owner 111 Applicable)
Ea et B nature Data of signature
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ROUTE/BOX NUMBER G C ( l \ l FIRE NO.~
CITY/STATE/ ZIP --c~
PROPERTY LOCATION: 1/4 NO 1/4, Section TR l
Town of -T /"o 61 St. Croix County,
Subdivision 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
DATE
i
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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 C DIVISION P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON W1 3707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: WNSH UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISI N N ME:
,
Oil
1/~V~J~/a /T N/R E to IN Z) e
OUNT.Y: BUY S NAME: MAI !VG ADDRESS:
sy, P44 #10: GO er
USE DATES OBSERVATIONS MADE
NO.BLEDRMS.: COMMERCIAL DESCRIPTION: PROFILED S RIPT ONS: A O TESTS:
iu residence ",Z ❑ New Replace //9 9
5 16
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S ou S au ~S ❑u oS WaS A
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 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- 1 ,eD 9 ? d o Q~ ISO ~W~i 6.8d
B-
B- a IOI~ ~o c~S
13-
3B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER WELLING INTERVAL-MIN. PERIOD 1 PER D P R PER INCH 0 AV /A*, P-
P_ GL ® a
D fl d!~
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
77- T q4 F
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1, 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 ( ri 1 TESTS WERE COMPLETE ON:
CERTIF A N N BE ~PHO E NUMB R(optionall: 'q lf ADDRE S 6 - 3 ~l II~ L 1?001 I
CST SIGN RE:
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
(Q To b Wornplete and accurate soil test, your report must include;
1. t jal description;
2. The section must clearly dii,rte : this is'a residence or commercial project;
3, MAXIMUM number of br;J >r----ns or commercial use planned;
4. Is this a new or replacemer, I;
5. Complete the suitability rtes. A SIT.'ITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE Rt, 'JT BA`, )IL CONDITIONS;
5. PLEASE use the abE for t ing profile descriptions and com ' the plot plan;
1, n ' KE A LEGIBLr m a. ,,;cating your test locations. Drawing to scK is preferred. A
sheet may
8. e your bent' I elevation Aerence point are clearly shown, and are,, permanent;
9. Con «!I approp, . ates, na dresses, flood plain data, percolation test exemp-
trun, u : Tpriate;
10, If the I ii r: ion (such as f elevation) :Jogs riot av -1 -e N.A. in the appropriate box;
11. Sign i'ie and place you it address and your cert, i i rmber;
12. Maki: I.: pies and d: as required. ALL SOIL MUST BE FILED VNITH THE
LOCAL, - ITY VVITI WS OF COMPLETION.
VIATION FOR CERTIFIED SOIL TESTERS
Soil Sr I Textures d r ''ymbols
St - Stc r 1011) EAR !...,ck
F cola Co 1011) SS ~,Jstone
gr - Gravel (under 3") LS Limestone
- Sand HGW High Groundwater
Coarse Sand Perc - Percolation Rate
- Medium Sand W Well
fs - Fine Sand Bldg Building
Is - Loamy Sand ) - Greater Than
" sl Sandy Loin) < Less Than
'`l Loarn gn - Brovvn
*sil Silt Loam BI Black
si - Sill Gy Gray
°cl C':y Loarn Y - Yellow
scl - rdy Clay Loam R Q-4
sicl - -:y Clay Loam mot - Iotties
sc - S=rdy Clay vvf -
sic :ty Clay fff re, faint
*c _ y cc coarse
mr llum
d
P - pi
HWL- H ,a a vel,
Six general soil textures s"„ _ er
for liquid waste disposal BM - Bench N'
VRP - Vert rce Point
v VNER:
Th is the firer+-~i*. The ce a or T ;west
l ti Ac f
Fans t.;i rvate
the app"o;° in order to
/ osted >r for f any constructir.)n.
y
ti
pot s ff6~
Cob- Ids A°,5~(w
m~w lS toue WI tak,
~w„nlar
Sys. ko, ~ ,a6
A g✓
re% ex rt Otp wf~~S to 1
jajc~a ~ec~ &e a Qh~one
qe~
~d SIL ( P D1,kt t~h
t~buo ~4l Septic
4r
100.0 S
0
l~