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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
Y'7 ,71b, 17W Reconnect Exlstln (ItatePlan I. Number
assigned)
Town of Erin Prair' ❑ CONVENTIONAL 3& ALTERATIVE
Co. Rd GG Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Rodney Forrest Route 1 Box 51E New Richmond WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM LAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Gar Steel 3254 St. Croix 128596
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 No
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF) I ❑ YES ❑ NO NEAREST 11111-
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
❑ 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:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLESPACING: 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
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88) Zoning Administrator
Thomas C. Nelson
SANITARY PERMIT APPLICATION
DILHR COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
ow~m~,rs
a~ .e~r,wu.e.a.anaa.~w,vr
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 02 ~~9~p
8% X 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Rodney Forrest N6' Y4 NW S 17 T 30 , N, R17 TF (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # /a
R.R.#I, Box 51 E n/a n
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
New Richmond, Wi. 54017 715 46-2360 n/a
111. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned ❑ VILLAGE Erin Prarie Co. Rd. #GG
X NUMBER(b)
.QF
❑ Public C41 or 2 Fam. Dwelling-# of bedrooms 3 AR EL TA
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 El Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash
5 ❑ 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. El New 2. El Replacement 3. El Replacement of 4. Reconnection of 5.E1 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 U 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
450 615 624 .72 class 1 96.90 Feet 99.90 Feet
VII. TANK CAPACITY Prefab. Site Fiber- Exper.
in allons Total # of Manufacturer's Name Concrete Con- Steel glass Plastic App
INFORMATION New istin Gallons Tanks structed
Tanks Tanks
Septic Tank or Holdin Tank x 1000 j-4 Powers F0
FP1
ift Pump Tank/Si hon Chamber -
L
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for inst ation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber' 9nature: ( S ps) /MPRSW No.: Business Phone Number:
Gary L. Steel 3254 715 246-6200
Plumber's Address (street, City, State, Zip Co :
988 N. Shore DR., New Richmond., Wi. 54017
IX. COUNTY/DEPARTMENT USE ONLY
Iss n gent Signature (No Stamps)
❑ Disapproved nits Permi ee (Includes Groundwater as as
rcharge Fee) /O
Approved ❑ Owner Given initial L
Adverse D terminatio
X. CONDITIONS OF APPROVAL/R ASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-87) (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.
Ill. 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.
Vill. 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)
Rodney Forrest
NWyNW4 S17 T30N. R17W
Erin Prarie, township
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G
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8
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14-12 g,-r, , o
Gary L/. Steel
L L /Oa 988 N. Shore Dr.
New Richmond, Wi. 54017
MRPSW 3254
t
APPLICATION FOR SANITARY PERMIT
S T C - 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 Rod= Forrest
Location of property NW 1/4 NW 1/4, Section 17 , T 30 N-R 17 W
Township Erin Prarie
Mailing address R.R.G, Box 51E
New Richmond, Wi. 54017
Address of site same
Subdivision name -1a
Lot number n.1a
Previous owner of property Wallace Dunn
Total size of parcel 1.7 acres
Date parcel was created
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for resale (spec house)? Yes x No
Volume 753 and Page Number 398 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.
---------------------------------------------------------7---------------------
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 warranty deed recorded in the Office of
the County Register of Deeds as Document No. 416886 - ; 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 County Regis r of D ed , as Document No.
Signatu f Owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
L
_ +.~ti h'~i.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , 1 DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS (H63.090) & Chapter 145.045)
LOCATION: SECTION: C TOWN SHI TY: LOT NO.:BLK. NO.=SUBDIVISION NAME:
NW ~,NW~/4 17 /T30 H/R171(or► W Erin Prarie
COUNTY: OWNER'S BUYER'S NAME: V.AILING ADDRESS:
St. Croix Rodney Forrest R.#I Box 51E New Richmond Wi. 54017
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 n/a ❑New Replace 6-30-89 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL OLD ING TANK: RECOMMENDED SYSTEM: (optional)
0 u Eas 0 U S U ❑ S a U ros ~ conventional
DESIGN RATE:
If Percolation Tests are NOT required If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 37 BxB
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTFM, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 17.50 98.72 none >7.50 1*00bl.l. .92bn. sil. 1.58bn.s.l. 1.50bn.l.s.
B-
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER PER INCH
P-
P-
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 96.90 _
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1-1-111 41-
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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 (print): TESTS WERE COMPLETED ON:
Gary L. Steel 6-30-89
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
2298/7A - 715-246-6200
CST SIGN RE:
ply/
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
.'JCTION,q FOR COMPL.ET11 a €M 11 - S BD - 6395
a ::t, yc ~13, RISC inraucle:
whetl )r coinmerci
r CosrllT
5, s A SITE ABLE ~LDING TANK ONLY IF ALL.
s _ -)UT BASEF- LC
_ -1Vn here
profile df ; and compel g the plot plan;
~ - *ely k r test locati. ~ is n I. A
I k e! ice point are y hol,vn, al `
Ioxcs as to (late flood I~ data, percolation test ( rep-
t
apply, in 'ate box;
~ 1.
as ;DIL TEST E FILM VVITH THE
L Y DAYS C; ~
"TIONS , ~1 IF(ED SEAL
~-J Textures Oth
sr 10") BFI -
D") SS
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si - I ,any ~I -
iariv
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VI,P I R ice Point
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/%W
ROUTE/BOX NUMBER R.R.#I, Box 51 E FIRE NO.
CITY/STATE New Richmond Wi. ZIP 54017
PROPERTY LOCATION: NW 1/4 NW 1/4, Section 17 , T 30 N, R _L7 W+
Town of Erin Prarie , St. Croix County,
Subdivision n/a Lot No. n/a
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 Zoni g Of ce ithin
30 days of the three year expiration date.
lz.,10_410.11 1
SIGNED
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street u
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address