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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BuiL ING
LABOR &AUMAN RELATIONS DIVISION
F*O. BCI1C 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
.1u1.E'D1SAN, I(V4 5 7071 } 1.6W Sf at s fined) 'Number:
1Town of C' yj11on CONVENTIONAL ❑ ALTERATIVE
210th Ave. ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION 13ATE:
Paul Ula ne Bell 435 Green Ave. New Richmond WI 8-11-89 2:OOPM
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:
Byron Bird JR 3318 St. Croix 128608
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ 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
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF PU ❑ YES ❑ NO NEAREST 11110-
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:
BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL EPTH DIST . PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: 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
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
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:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
~5 _
Sketch System on c Retain in county file for audit.
Reverse Side. SIGNATURE: Cning E:
S B D-671 0 (R. 06/88) f~ Administrator
Thomas C. Nelg.on
SANITARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code
7DILHR
- STATE SANIT Y PERMI
laps (to the county copy only) for the system, on paper not less than I~ ~Q Q
Attach complete p ❑ Check if revision to previous application
8t% z x 11 inches in size.
STATE PLAN I.D. NUMBER
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P OPERTY OWNER l PR P RTY LOCATION
1115 11111 , A4WEE ~
IIIIA -Pi/~/a '/4, S T N, R E (o 11 11 11' 1 11 LOT # BLOCK #
PROP TY MA IL G ADD ESS
n
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
L O! 1 r.2(146 W,
NEAREST ROAD 2
vii GE : /Tv
L-i II. TYPE OF BUILDING: (Check one) ❑ State Owned
R TOWN OF:
t~ 3~ a
❑ Public ;&1 or 2 Fam. Dwelling-# of bedrooms A EL AX NUM R ) tly
III. BUILDING USE: (If building type is public, check all that apply) /
1 ❑ Apt/Condo ❑Outdoor Recreational al Facility
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 11 El Restaurant/Bar/Dining
Recrea 3 ID Campground 7 El merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash
4 ❑ Church/School 80 Mobile Home Park 1g ❑ Other: Specify
50 Hotel/Motel 9 ❑ Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1 New 2. ❑ Replacement 3.0 Replacement of 4.0 Reconnection of 5.0 of an
System System Tank Only Existing System Existing System
,
Date Issued
B) ❑ A Sanitary Permit was previously issued. Permit # -
V. TYPE OF SYSTEM: (Check only one)
Other
Non-Pressurized Distribution Pressurized Distribution Experimental
11 Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El Holding Tank
~
12 Seepage Trench 22 11 In-Ground 420 Pit Privy
43 ❑ Vault Privy
13 ❑ Seepage Pit Pressure
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PER. RAE 6. SYSTEM ELEV. 7. FINAL G A E
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (
6eD I~Z Feet / • Feet
CAPACITY Prefab. Site Fiber- Exper.
VII. TANK in alIons Total # of Manufacturer's Name concrete Con- Steel glass Plastic App
INFORMATION New istin Gallons Tanks strutted
Tanks Tanks
lG~e
Septic Tank or Holdin Tank FF F~ I Lj
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
MP/MPRSW No.: Business Phone Number:
Plumber's Name (Print): Plumber's 'nature: (No Stamps r
, 174(l
Plu er's Address (Street, City, State, Zip Code):
r// 6r
IX. C UNTY/ EP RTM NT USE ONLY Iss m Agent Signature (No Ste ps)
Disapproved nits Permit Fee (Includes Groundwater e ssue ~
Surcharge Fee)
Approved El Owner Given Initial - d -
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
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 one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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)
INDUSTRY, 'uli tip" ii~ra ryas rvav • Uiv Wwty P.O. BOX 7
LABOR AND PERCOLATION TESTS (115) MADISON WI 537097
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
L ATION:, r , SECTION: OWNSHIP UNICI ALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
r ~/i / /Tj N/R/( E (o C cry -
COUNTY: OW R'S YER'S NAME: AILING ADDRESS: L w YCJ 'l
CD i B I)q3 6. G re e C C/J/"z ~f/ KJJ
USE 24 DATES OBSERVATIONS MADE NO.BEDRMS.: COMMER IALDESCRIPTION-r-
: I ERCOLATION
ES RIPTION R FI
~Residence =New[:] Replace (J/S 7
YYY
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIOtVAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: loptional)
ri ZU
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL =;ATIONPQBSE R UNDWATER-INCH 5 HARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, T.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
6 61441 /j 4-,7.0 All 03.7 - -agy jo.'? '5
B- > S u~;
Qn c
B-3
4-• ?/j~.~„ ~-.2~ f,'l.ZO X3.7
B- q 'K Lj Mot A C i~~
B. p~ .sr >
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DRO IN WATER LEVEL-INCHES RATER INCH MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERIOD
P. a o ' a y
P- ° J
P- 3 a,
P-
P-
i
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
Tr
of land slope. /SL► J
SY EM ELEVATION a -ten
-53000 0-1j,
b'r sa " Gc>J~ r 1`G Qli 1 e."J 47 x `Ttv ter;
4CJ /d ! r. A.
1,10 V
Ili-
a o Rio s k
1
Pia
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 lp t : t TESTS WERE COMPLETED ON:
_MD-DRES91 CERTIFICATION NUMBER: PHONE NUMBERIoptionaq:
s 6 711
d~C ter` Lt1i ~c. ce / !~D -7
CST SIGNATUR
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. a
DILHR-SBD-6395 (R. 10/83) - OVER -
.r
+ 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 Lct, 1_4 1/°~n"c'- 'ae-
Location of property ~2 W 1/4 1/4, Section T 3 -R-LW
Township CC IO Y\
Mailing address )y3 PYN
Address of site
Subdivision name
Lot number
Previous owner of property d-f r
Total size of parcel ~l~ ~'~C f eS
Date parcel was created a3- 9_~
Are all corners and lot lines identifiable? es No
Is this property being developed for resale (spec house)? as No
Volume and Page Number '!il_ 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.
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 1(.'deed recorded in the Office of
the County Register of Deeds as Document No. `1 3 3 19 7• ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
',L/
Signature of Owner Signature of Co-Owner (If Applicable)
U
A? 7
Date of ignature Date of Signature
' ,.1♦D000MENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
i
~ STATE BAR OF WISCONSIN FORM 2 1982 REGISTERS OFFICE
433197 4VGt. 799 PAGE 459..____-._--_ ST. CROIX CO., WI
- Recd for Record
Dec. 23, 1987,
John---W..... QQden--- at 8:30 A M I
- Register of Deeds
conveys and warrants-to P_au1__W___Be11-- and_.Niana Be_ 1._
~ I
husband---axed--w iEe ra--s---s~axv-ivo_rshig.--mar.ital
pzoge_rt-y__•_______________________________________________
-
s RETURN TO
t
St. Croix
the following described real estate in County,
State of Wisconsin:
Ii
Tax Parcel No-
Part of the Northwest Quarter (NW 1/4) of the Northeast Quarter !
(NE 1/4) and part of the North Half of the Northwest Quarter
j; (NW 1/4) of Section Nineteen (19), Township Thirty-one (31)
Range Sixteen (16) described as follows: Lot 3 of Certified li
Survey Map filed July 26, 1976 in Volume "1", Certified Survey!
Map page 277 as document number 334433. Together with and
subject to a 66 foot easement for ingress and egress over the
Southerly 66 feet of said Certified Survey Map.
I ~
FED
is not
This homestead property.
(is) (is not)
k I
Exception to warranties: municipal and zoning ordinances, easements and
restrictions of record.
Dated this day of _________.December °L 87
19--------•
--------------------------------------------------------------------(SEAL) (SEAL)
John W. Oden
I
--------------------------------------------------------------------(SEAL) - - (SEAL)
s=
i
AUTHENTICATION ACKNOWLEDGMENT
oh11 WISCONSIN
Signature (s) - - - - Q~eX1,.------------------------- STATE OF
i
sg.
County. I
a _ _
4 authenticated this '~_____day ofDe_g_elnbr..... 19.7_ Personally came before me this ----------------day of
19-------- the above named
4141-
Judith-_A._- Remingt--n-----------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BYI
___REMIN.GT_QN---LAW-_ QEEICES---------------------------
Juditb A. R~min ton
Ke-w--- RiG m4ri ,--_7n i-------- 54-117-------------------- Notary Public -----------------------------------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) '
date- 19--------•) I;
tli
i 'Names of persons signing in any capacity should be typed or printed below their signatures.
it
L . . _ - _.___._-----._...--__.__._._-..-......._-..._......___....---._.___J
STATE BAR OF WISCONSIN
H.QMiIIerC;cnvwy~ FORM No. 2 - 1982 Stock No. 13002
YII.r.uY.e, WIKOnYIn
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER fiaf-+ ondo rya T, 1
ROUTE/BOX NUMBER /y 3 S' G1'~ PkA FIRE NO.
CITY/STATE j w C1CAM0r-'A_U'f ZIP C,) Z161
PROPERTY LOCATION: H 1/4 1/4, Section T_I N, R_jL_W,
Town of 1011 , St. Croix County,
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
Subdivision.../// , Lot No.
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 172 2
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
PLOT PLAN
PROJECT utic K .e' ADDRESS % S ~"un U~ m
A X14 1/4/S`r' /T p N/R /G W TOWN CQ S Byron Bird r. 3318 DATE
BEDROOM CLASS PERC_,-f- CONVENTIONAL IN- ND PRESSUR
CONVENTIONAL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
1116 Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
* H.R.P. Al-Z" Go pro /j
I= Borehole Q Well Scale = Feet
0 Perc Hole System Elevation Gl 3.
Uent
12"
Grade
TYPAR COVERING
2" _
12" 3• 4 6" ® 3"
1 6 " Sewer Rock
12"
h~rJc.•wK -
If
4 4*1 If
0 _
Ilk
`oo ~latx o 15
6"