HomeMy WebLinkAbout006-1054-40-200
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ''TT ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
'g I4o,f,LU V4;§'76C.Cylon 24, T31-R16TT-T State Plan I.D. Number
T
Town o J0 f u CONVENTIONAL ❑ ALTERATIVE (If assigned)
To
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 6 moo a)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Robert Berndt Deer Park, WI 54007
BENCH MARK (Permanent reference point) DESCRIBE IF DIFF RENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: - MP/MPRSW No.: County: Sanitary Permit Number:
Lyle Myers 6219 St. Croix 112827
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKNG 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 i I ~ ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST 1110-
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 DEPTH DISTR. 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
[DYES ❑ 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:
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 El NO El YES ❑ NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PRO RTY WELL: BUILDING:
FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST ►
Pe~(1 Vf v~ VU ll~t.S e C!
~S f a~ 2311 q JV1
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06188)
I
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number:
SE 4 j SW--,, Sec. 24, T31-R16 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Cylon ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Robert Berndt Deer Park WI 54007
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:
Lyle Myers 1309 St. Croix
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
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: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AIR VENTT5T. FRESH
(DIFFERENCE BETWEEN FEET FROM LINE
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: 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: =DEPTH W 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( F PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST,
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION COUNTY
1 ILHR In accord with ILHR 83.05, Wis. Adm. Code 't r ° {
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
'/4 '/4, S T l N, R i.' E (or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK
❑ VILLAGE
117-1 TOWN OF*'-J.1- 1
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. ❑ New b. ❑ Replacement c. ❑ Replacement of d. E:1 Reconnection of e. E1 Repair of an
System System Septic Tank Only an Existing System Existing System
2. A sanitary Permit was previously issued. Permit i Date Issued %-7:
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in ##2)
1. a.❑ Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ seepage Bed b. ❑ seepage Trench C. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet ❑ Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total of Prefab. Con- Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete str cted Steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank 4: ❑ ❑ 0
Lift Pump Tank/Si hon Chamber
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code).,_ Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST
lrv1, t 3i
CST's ADDRESS (Street, City, State, Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate 71i_suing Agent Signature (No Stamps)
Surcharge Fee
Approved ❑ Owner Given Initial
Adverse Determination I - { `
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
4 ~
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION Y
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
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; dosing or pumping chambers; 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.
- - - - - - - - - - - - - - - - - - - - - -
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground*ater
included the creation of surcharges (fees) for a number of regulated practices which Wiscorisin's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buriedreasure a
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03/86)
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' 1~~D
H C CROSS-SECTION
Approved Weather Proof
Vent Cap Junction Box
411 C.I. /Approved Locking Manhole Cover
Vent Pipe With Warning Label Attached
Minimum 12" And Padlock ~
/Final Grade -4-Minim
um
,
f Approved Joint -
18" Minimum
Dater Tight
)eal High Water '
SPECIFICATIONS Alarm Switch 0 u T
T
TANK New ?1~ Existing -
Manu a cturer• Approved Joint
Tank Size: s Gallons--- tI~ i~ w/ C.I. Pipe
-944=4- C.I. Extending 3'
Plug ALARM Manufacturer: S Onto Solid Soil
Model Number:
Switch Type
NUMBER OF BEDROOMS:
GALLONS PER DAY: c6
3" of Bedding Under Tank
Owner's Name: Address: c3 9(A) I TC_ <
Legal Discript1on,
Township/Munici al ty:, " /~Z/a,,e L L-~ u
(!i
County:
f
PLUMBER/DESIGNER
Signature:
License N~ r:
Date: /10
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AS BUILT SANITARY SYSTEM REPORT
'WNER A4 TOWNSHIP r, :I SEC. C T N, R
r.0. AD RESS , ST. CROIX OUNTY, WISCONSYN.
'UBDIVISION , LOT LOT SIZE V_Vre S
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
PC,
l
~ ~ _ ~l a vv .
l v nC
• i I Ll e -
C/ f,
~t
76- c, At /4
'IPTIC TANK(S)CONCRETE STEEL
NO. of rings on cover. Depth DRY WELL
aENCHES NO. of { width 1ength area
:D no. of lines
width f L length , "area
t;
depth to top of pipe AV-' z
GREGATE l
ARK RATE AREA REQUIRED] AREA AS BUILT
sclaimer: The inspection of this system by St. Croix County does not imply complete j
)mpliance.with State Administrative Codes. There are other areas that it is not possible
I inspect at this point of construction. St. Croix County assumes no liability for
-stem operation. However, if failure is noted the County will make every effort to
2termine cause of failure.
;EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
-'INSPECTOR
r
DATED PLUMBER ON JOB
LICENSE NUMBER
i
Z.
REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM
San.ita,%y Pe&m.it-42919
State Septic
NAME ,°lTownehip St. Cno.ix County
S e cti o n~~T.31N R W
Locatiov~% 0 ~ 4,
SEPTIC TANK
i
Size ~,x X7.7 gaZtonz. Numbers 96 Compatctmentz
Viztance F,%om: We.2~~~ ~ 6t. 12% on gneate& b.2ope - 6t
Bu.itd.ing W etZandz '6--.71C bt.
H.i9hwaten06t.
DISPOSAL SYSTEM
Ii
o an gneaton stope 6t.
D.cdtance Fnom: G1e.E.2 12a
Bu.itd.ing 6t. Wettands Ft.
High wate,%-l
FIELD DIMENSIONS:
Width o6 ttcench 6t. Depth of tcock betow t.ite_/2- in.
f
Length o6 each tine 0 6t. Depth o6 xock oven t.ite Z. in.
Numbers. o6 Zi.nes ~ Depth as tiZe betow grade=s ( .in.
Totat. .length o6 tines(est. Stope o6 ttceneh in pen 100 6t.
D.i,ztance between tine.a Ca~ Depth to bednocfz S .
Totat abb o&bt.ion area-J<,,~-6t2 Depth to groundwater 6t.
Requited atea 6t2
PIT DIMENSIONS:
Numbest o6 p.itz G vet ateound pits ye,6 no
Outz ide diametett th betow inlet 6t.
2
A v-
Totat ab.sonbtion a,%e 6t
AtLea nequ<in 6t2
INSPECTED BY ITLE
r
APPROVED , '9ATE f (v 197
REJECTED , DATE 197.
S
PLB67 State and County State Permit # -
Permit Application County Per '
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:
A~V a
j W
B. LOCATION: 1/4 ection T N, R (or) . W Lot Cit
Subdivision N e, nearest fral( lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste GrinderYESNO # of Bathrooms
Automatic Washer XYES NO Other (specify)
E. SEPTIC TANK CAPACITY Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb AreaO sq. ft.
New Addition Replacement *Fill System
,lot
Seepage Trench: No. Lin. Feet Width Depth _Tile Depth No. of Trenches
Seepage Bed: Length Width Depth Tile Depth _ No. of Lines - .2 006,
Seepage Pit: Inside diameter Liquid Depth Tile Size 4
Percent slope of land / LC Distance from critical slope o~
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 S 'I Tested, r
NAME J C.S.T. and other information
obtained from / (owner/builder).
Plumber's Signature MP/MPRSW# Phone
Plumber's Address
PLAN VIEW: Provide sketch d elow of system (include direction of slope and all distances in accord with
H62.20, including well).
v1 Q ~
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IN
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481`- e--3 fro " ~kc
7- ~K;t he 7/-
Do Not Write in Space Betew FOR DEPARTMENT USE ONLY
Date of Application -0 Fees aid: State ,Q r p Q County Date
Permit Issued/Rejeefed (date) Issuing Agent Name
Inspection Yes No Valid# Date Recd
1. county (whit k opy) 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
EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES ~..~Z - ~S`t~.•
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309 Il 1
MADISON, WISCONSIN 53701]
~/REPO~RT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION. =%/4, Sectia~~, T_/N, R ~ (or)(~jTownship or Municipality
Lot No. ,Block No. County Alk.
division Name
Owner's Name: G'am' r~
Mailing Address: ® ,e I w
TYPE OF OCCUPANCY: Residence -)e No. of Bedrooms - 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT /
DATES OBSERVATIONS MADE: SOIL BORINGS € PERCOLATION TESTS
SOIL MAP SHEET SOIL TYPE
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_/ I
P-2
P y7%
( i
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
t
3
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4, A ;2. <
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suits a greas. Indicate n ber ofp - are~feet absorption area
needed for building type and occupancy. f4- / P l ~t`~ l Px.rE s indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
nd 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.
Name (print)' Certification No. 5_~1 Se
Address
Name of installer if nown
CST Signature ~
COPY A -LOCAL AUTHORITY
PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES
• Division of Health
FEE $10.00 PD. Box 309 NO. 7336
(I Permit per Tank) Madison. Wisconsin 53701
Date Issued Tank Size 12 0 qw.
STATE SEPTIC TANK PERMIT
Private Res XX X This copies:
e1-Property owner
permit is for purchase of septic tank only and doss
not exempt installation from state or local approval (Pi-Tank of Health
Public and/or permits. (canary)-issuing Agent
Owner's Name ' Owner's Address
Robert W. Bernd Eagan, M.i.nnuota
Location (Legg Description) of Property. Where Tank Will be I taUed County
SE% o6 SW% o6 Section 24, T31N-R16W, Cy.ton Sze Cno-i-x
Plumber t Name v`x"AP°' 1309 AdaressA men y, W.i..6 .
loe
Siena Address if Other Than Owner
Byron B.ucd Amery, W.ibcondin
Address of Ismft Apat (Town. Villag. City) County
O.t.d Couxthouba Bu.i,.td.i-ng, HudAon, WiAa n4 in St. Cno.i-x
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Parcel 006-1054-40-200 02/08/2007 11:19 AM
PAGE 1 OF 1
Alt. Parcel 24.31.16.369B 006 - TOWN OF CYLON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
01/04/2006 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-owner
O - BERNDT, ROBERT W & KATHLEEN M
ROBERT W & KATHLEEN M BERNDT
2526 200TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 2526 200TH AVE
SC 1127 CLEAR LAKE
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 24 T31 N R16W SE SW THE W 1/2 OF SE Block/Condo Bldg:
SW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-31N-16W SE SW
Notes: Parcel History:
Date Doc # Vol/Page Type
01/04/2006 815608 QC
07/23/1997 870/13
07/23/1997 781/550
2007 SUMMARY Bill M Fair Market Value: _ Assessed with:
0
Valuations: Last Changed: 06/13/2006
Description Class Acres Land / Improve Total State Reason
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
"MADISON, WI 53707
SE,1,4,SG14,S24,T31N-R16Gi, 1~kONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
(lf assigned)
Town o j C yt o n ❑ Holding Tank El In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Robett Berndt Dee& Pa&k, Gil 54007
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW N,, Counly Sanitary Permit Numll
B non R. Blind 1309 St. Croix 112&27
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. IWARNINGLABEL LOCKING COVER
PRODED. PROVIDED:
DYES ❑NO DYES ❑NO
BEDDING: VENT DIA.. VENT MATT HIGH WATER rUIMBER-OF ROAD: PROPERTY WELLBUILDING: (VENT TO FRESH
ALARM ET FROM LINE AIR INLETDYES ❑NO DYES DNO EAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY JPUMP MOUEL JPUMP,SIPHON MANUF ACTIIHEH WARNING LABEL JLOCKING COVER
PROVIDED: PROVIDED:
DYES ❑NO DYES ❑NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENTTOFRESH
(DIFFERENCE BETWEEN f FEET FROM LINE alR INLET.
PUMP ON AND OFF) DYES ❑NO NEAREST 30
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing '-111 IIIIArm TER 1111ATIRIAL AND MAHKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM: _
BED/TRENCH WIDTH LENGTH t0EnQaiES DISrH PIPE sPnc:INC, COVEHIAL PIT wsIOL DIA -PITS pQTD
DIMENSIONS
(]RaVFL DEPTH FILL DEPTH DISTH PIPE DISTH PIPE DISTR. PIPE MATERIAL NO DISTH NUMBER OF 'PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END PIPE S - LINE AIR INLET.
FEET FROM
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ❑NO
SOIL .`OVER TEXTURE PF HMANE NT MAHKE HS OBSERVATION WELLS
_ DYES ❑NO DYES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED UEPiH OF TOPSOIL SO UDF II SEE DID MULCHED
CENTER EDGES DYES ❑NO
DYES. ONO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATEHAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PI=7PCOVERMATEHIAL NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.: ELEV. CIA. ELEV. PIPES DIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT (,Y PLAN SCAL LIFT CORRESPONDS TO APPROVED
DYES ONO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE.
DYES ONO DYES ONO _ NEAREST-
' ~4
Y Y~~
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE'.
Zoning Adminisxnaton
DILHR SBD 6710 1R. 01/821
SANITARY PERMIT APPLICATION COUNTY
(~IDILHR In accord with ILHR 83.05, Wis. Adm. Code St. Croix
STATE SANITARY PERMIT #
/ `9 $ a 7
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ~ NO
PROPERTY OWNER PROPERTY LOCATION
Robert Berndt SE 14 SW % S 24 T 31 N R 16 E (or)&j
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD, LAKE OR LANDMARK
Deer Park WI 54007 715 463-31121 El VILLAGE .Cylon
f7l
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 4 OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. ❑ New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ® A Sanitary Permit was previously issued. Permit 233 Date Issued 8-7-78
3. An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in #2)
1. a. K] Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. [See a e Bed b. ❑ seepage Trench C. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
9 820 820 Feet ® Private []Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. C Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete str cted Steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank Conc. [Z Ll
Lift Pump Tank/Si hon Chamber ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Byron R. Bird 1309 715 268-8317
Plumber's Address (Street, City, State, Zip Co e): Name of Designer:
Rt. 1 - Box 228 - Amery, WI 54001 Byron R. Bird
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST # 1854
Irvin Stolp
CST's ADDRESS (Street, City, State, Zip Code) Phone Number:
Taylors Falls, MN 55084 612 454-5270
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate issuing Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee
1 Z Q ~ qg n c, f 6-f '7 _6" '
Adverse Determination `l.D ~+J G.•~
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMP-LETING A SANITARY PERMIT
APPLICATION 4
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8X, 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; dosing or pumping chambers; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground Ater
included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure<
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater, 777
it's worth protecting.
SBD-6398 (R.03/86)
PLOT PLAN i
PROJECT d ~e-g 7 A~ DDRESS f~ c CA, ~ J~ J~ o U
COUNTY ~.T laf~Eg
1/41/4/So2y/T,?% N/R / W TOW14 (7j
MPRS Byron Bird 13 u DATE ~r I
BEDROOM -4 CLASS PERC CONVENTIONAL_ IN-GROUND PRESSURE
CONVENTIONAL LIFT MOUND_ HOLDING TANK
SEPTIC TANK SIZE / rr LIFT TANK SIZE'S
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA J ds PERC RATE A6 f BED SIZE 719
k Benchmark V.R.P. Assume Elevation 100' jW11Al44
Location of Benchmark r> { _ fi, H S-e
* H. R. P. - - -
0 Borehole 0 Well Scale = Feet '
O Perc Hole System Elevation F'
TYPAR COVERING
2"
12" 3' (D 6' 0 3' 3' O 3' 3' O 3'
6" Sewer Rock
12' 18, 24'
11A,iT ~
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_Eli 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES ! -o DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 308
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: 'L-44, Section T. ,LN, R 1_"f (or)-W, Township or Municipality
County
Lot No. Block N9 (vision ame
Owner's Name: C"
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT _
; -
DATES OBSERVATIONS MADE: SOIL BORINGS 17 e PERCOLATION TESTS l `
r
SOIL MAP SHEET SOIL TYPE
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL
BER PERIOD 2 PERIOD 3 MINAN
NUM INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1
I P 49',~__
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
r c~
77
.iw.'
PLAN VIEW -(Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suits l~e areas, Indicate number of square-feet of absorption area
needed for building type and occupancy. E-- i _ , - Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
11 T 1 i 1)
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the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
nd 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.
Name (print) Certification No.
Address