HomeMy WebLinkAbout014-1044-20-002
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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER fiQ,.i7A-f4.riwwjrcQ[ nn:M TOWNSHIP SEC. 21 T 31 N-R
ADDRESS BOX ST. CtjOIX COUIJT i , WISCONSIN
~ln.~~T~kl~l rJ ti
SUBDIVISION /ZQ LOr PJ/ A- LOT SIZE 0,C q'9-
PLAN VIEW
Distance- and dimensions to meet requirements of ILHR 83
SHOW EVERY )'111t1G WITHIN 100 FEET OF SYSTEM
(o5~
l J~/ t
1 =
2D
ax ~
RAk
INDICATE NORTH ARROW
BENCHMARKS Describe the verticnl reference rni.nt used p C6- C8u-aexr
Elevation of vertical reference point:
jM) -0_ -Proposed slope at site.
SEPTIC TANKS Manufacturer: _ Ll ;i,id Capacity: Jum Cwt
Number of rings used: Tank mnnho i.e cover elevation: TD*tt j,~~•
Tank Inlet Elevation: Tank OuLIt A i:.t.nvation: '
Number of feet from nears i t:-.id: Front:, L:,!~,ORear, O ~ ~O'D feet
• From nearest- ptoE,cl. Unc 0Rear, 0 feet
-
PUMP CHAMBER
Manufacturer: a Liquid Capacity :C
Pump Model: Fatri+p/Siphon Manufacturer: ~C Pump Site 4110 Elevation of inlet: Bottom of tank elevations
Pump off switch elevation: Gallons per cycle: ac T$c,~
Alarm Manufacturer: !g, ~QC~sa Ra - Alarm Switch Type: U gAcv.a 1 ad _
Number of feet from nearest property line: Front, Side, O Rear, Q Ft. 6's
Number of feet from well:
Number of feet from building: /
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Beds Trrn ch:
Width: Leoths Number of Linea: Area Built: Fill depth to top of pipe:
Number of feet from nearest property line: Front, ® Side, O Rear,0 Yt.(os-
i
Number of feet from-well: Z_ 46
Number of feet from building: ~ /Da
(Include distances on plot plan).
SEEPACB PIT
Sizes ~p Numbev of pits: Diameter:
Liquid depths ~ Dottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O 'been used on any of the above soil
absorbtion sytems?'(Check one).
HOLDING TANK AA_
Manufacturer: 1~ Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector- _C;~, "A
Dated! %0/f7 Plumber on jobs
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License Number:
3/84:mj
QG~
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7LT" -74
d V4-
.RTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
,OR & HUMAN RELATIONS DIVISION
J. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
AADISON, WI 53707
State Plan I.D. Number:
NW4,NE 4, Sec. 21,T31-R15W❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Forest ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
F rr MJR~h ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
David Tumm R80, Emerald, WI 54012
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:
4ohn P. gukora 3212 St. Croix 128688
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: PROVIDED:
E:1 YES ❑ NO [__1 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
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:
BE TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
ENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES-. COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
ound site_p ed 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:
DIMENSIONS J TRENCHES:
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: R MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO COVE ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Ay?. 5, 0
_31- 10,17-
(7
GI 3. 2-
7
~Cti n ' MA/lYaL ,v vh 3 . Z
Sketch S ste on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88) ~ :IP'~ / Y
SANITARY PERMIT APPLICATION
70ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY 011
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than E] / r/~
8% x 11 inches in size. chec 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. fj O o~ (d
PROPERTY OWNER PROPERTY LOCATION
/V()'/a C%,S?,( TV,N,R/,S E( r)W 04 PROPERTY OWNER'S MAILING ADDRESS LOT # K #
o N/* BLOC IA-
CI , STATE ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned r~ VILLAGE ~~,.(Z 216 ❑ Public 1 or 2 Fam. Dwelling~# of bedrooms 3? PAP0=14 QF: R ELTAX NUMB R( )
III. BUILDING USE: (If building type is public, check all that apply) 3Z~ i '1"
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
50 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. 9 Replacement 3. ❑ Replacement of 4. ❑ 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 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
Al 50 / $-7a 2 tz . 21 /dL `~'e Peet OS'1 eee
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
Septic Tank or Holdin Tank S
Lift Pum Tank/Si hon Chamber fmp 13
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsits sewage system shown on ttached plans.
Plumber's Name (Print): Plu T ier's Signature: o S mps) M /MPRSW Business Phone Number:
-715 J56 4"
&8e, & t4 -75 iul_ er's ddress ( t, City, State, Zip Code:(-,/ , /
n b
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater a e ssue Issuing Agent Signature (No Stamps)
, n
Approved ❑ Owner Given Initial Surcharge Fee)
Advers rmination O( -7,j
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
Y '
INSTRUCTIONS
f r
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.
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; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
requifed 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)
2
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
_JIL4 i L cc u v-. 9- w, vH
Location of Property - 10 -~6 JV_E k-, Section ;1 , T 31 N-R6' W
Township _ r•~ c
Nailing Address O u
s 1~ moo / Z_
Address of Site Gt S
' I
Subdivision Name
.Lot Number
Previous Owner of Property L e-Q jd ,CA wl
Total Size of Parcel V-P_ S
Date Parcel was Created PrItle :6 7 01 ct~
Are all corners and lot lines identifiable?` Yes No
Is this property being developed for resale (spec house) ? Yes No
volume 7q5 _ and Page Number '.S7/7 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
i (We) ceXU6y that att statements on thin onm cute true to the but 06 my (oun)
hnowtedge; that I (we) am (ace) the owneA (e f o 6 the pnopen ty dens ch i.bed in thiA
in6onmatti.on 6o4m, by vi tue 06 a wavcanty deed neconded in the 066ice o6 the
Co Regc,d
County ten o Veedls as Document No.
6 /7 ,and that I (We) pees en.tey
own the pnopoeed site bon the sewage dizpoe .bye em (on I (we) have obtained an
easement, to nun with the above duclri.bed pnopenty, bon the conetnucti.on o6 eai.d
system, and the game has been duty neconded in the 065.ice o6 the County Reg.fsten o6
Deeds, ad Doeament No. NVA-
SIGNATURE OI? OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
Aft
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land D.
Imam
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4 hsralnsle, on home ft M'spoll , teffedw'*A do
ISPNOW" IMOWWb (as OWN
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get 13-31-15 except that parcel described is
of IIF and 3E;c
Ilapo ;at Page 600
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St. Ctois County, Wisconsin. yr.
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Womb" P101"I
ft,"If am to WW U rsx at . the
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b t + 1M Mr tiwa ae i, t rrs~►.
i► Afi~ i gyn.
pastsn tf~e a't. c►.
r lift of No~rwber, 1987 and
"='a~e~tt thereafter;
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bdsma dM M MY In Lai N w Wdn tiffs............ t...,r+►+ -1 19 880M at ft
MM"A No@*% & wood W*MMt 8" tips. on&=" W
saw* ft "W as hire a mutt la~MM~t t~
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~s aa~i awaiwi i~s~nr ~auinas ~Yrs MU
~r 1r:~I1 +iii~liu. wM ir. i«i a~wa~s astiaa~l i~► tfis lYriie _
~e te+rM aums% iM ilk
IM11 ln1~IMMr iRi Mai Into an MMw ft"
Mam
iw s iwarif•as IM wNH bd at tie ffeft A@dW ash dIWIle x
~ WitwMUrst.drff8 •at M te+ssMi a, i• ~Nlt attlff sd~nt 1s
~IAti kAMN t tr fs sarii ease aaniat iet~sast has aawtl sMA► sMsM
his arrw~t Misis vW tad"ftm waN !nw Uaw W do mud*
1~MM
i t rMlt sMYIH'1awM~ *a be amt6nN is 69 swat at a1i aL>~i~
•...•WORM bobs kb•~•a•• 418d," -..cff...
inlr r twMiffMi ~~111 Ma tlW Y *I by Ys Wk wld r IN601",ft lytri r f~
""to taxes shall be prorated to-September 30, 190
w Itis13° pr lttg 9/12ths and Purchaser paying 3/12ths when dose.
Price, shall be allocated as follows: Homestead-
#S} i 4. aad ootb"JAIngs-$43.000.00.
#i► as *06 of bow *0 WNW". U Wk adieu is is dw *M Of as dWka R a *a
~r `#Ilk i Is w- . M.1halof
.....-r...~,i »
r
E r ; yr , t. x.
x,.
~ ~ ~.s~ INimd • Ms le's!~ ~ s~?~
M ~ ea egwMm t s" pGFMML
e pwr~almt en y insured (mss su
y I NO _ rMr require, w eri~raaa►1 ,
. mbsti pVWAW M" M& M
do imsersom P wllwi i
ethtwism a/~ la
slla~r et ♦aadmm+lrtmtmnmt undo aaiem Vendor
i. i be dspsllmd wtib Voador. Parebanr Am iw
wrifiai.
n.+s.Mm smdme. mile lsseimsar and Vendor otbmrwimm is
ba ~W-1 • ~MiM et negate « do peepsety dmnks~md, previded the Vendor dear tM reslmemM~s w i ,
essisrdrm Judi W
lltri.mr smom r rat r emssait wash ser aSsw waste to be committed on the Property. M ime~ leis
Ab Cr.~i
Is s txtx..maia ale ropsir to 00 Prepeety free from liens superior to w Hen of
tr &61* W", ail aw...Mm WJ >r,t~l..m siri.g the Property. flow
Viadsr aa~ tint IN mums ft perAws prim with iateeest and other moarys shall be "d err an
salt be d.br psrwms I at tY tiw and Is tbo nary "Levu speeMed, Vendor wW an demnad. e■mm.ls a~
do IM1.ue. a Wmrsrty N4 4 , In be sk*% of tbs Property. free and clear of ail !inns sad ess.srlns.nmy,
aq W aestmt tea or defmak of Purehmer, and o wept. - Mu nieip~ .
- -its record aA recorded easements-,-••res
...fY..ri _ts ..9f M:._.._..._ - -
wARxsM~Mt~S(pen Ant -time b of the osmesee sad (a) is the event of a default in the payment of esy pe%dPdsf ;E
(Newt wYi suften ire • pmried of ..-AO..- asp fellowing the specified due date or (b) in the event of a dmw~1. ;
cwt obi g@*o of Paxhmer wbirb smUsues for s period of ..30.... days 'oilewioH ~rMlrs•;
M diweed peeseMSy er smiled by eeelified mail), then Use entire outstsadiay bslaaa !5- MY
iYt dM and pgaMe in fail, at Vendor's option and without notice (whieb ParehaaK
vendee sbm>t ails bNo tM tipYb sad remedies (subject to any limitations prevMsd bah r
s irjrwar it eamif, Vsadec may, at his option, terminate this Comtreet end
-x11Mo and intsmNR jn do ~se~eel~ and smom the Property back through striet foreclosure wkb M
r be Man" mss. lasrlmser's fall payment of the entire outstanding balance, with interest tbsersn
is Mr's#its is► miles! en aeeh doleaedetbsramombdusbereandet (inwhiebo~ap amsuntr
W" be feeedslad as IigaWated daeraSes for failure to fulfill this Contrset sad m testa! lime
eel
K !Ws M rsdssnl; ur (ii) Vender may sue for specific performance of tilde Coatreet to
ale jmOrt e[ Me writer wtmtsadiag 6alanee. with interest thereon at the rate is effect on the dsM efE
' ; eAlimr amounts dos bermsndsr, b whkh event the Property shall be auctioned at jodieW sale sad
ddhd- Vendor may sue at law for the entire unpaid purchase price or my
) s its Contrast at an end and remove this Contract ssaeiod an title is a
1M e j1 Ms~ et pnseiMSr is iashmmeast; and vendor may have Pnxbsom ejected trap Msmxlads
amt a' rm4wr M collect any rents, issues or profits during the pemdeney at say smeller
it pl► aMex~ stiy onl err written statements or actions of Vender es eMmtM ei slip '
s' 1 air e.iy bobindingupon Vendor if and when pursued in litigation W W costs and e./tsmi
1 ` _ YIIiiI isms of Vmdee eurred to enforce any remedy hereunder (whether abated or sat) to in
2+ nisi elfrsnsss of tM@ evide►ee shall be added to principal and paid by Porebsom as i.
Is MW i IN I
a1a11MINGU mat oe tbs Pss6 of sy action of foreclosure of this CenUvft Parkins! amnmm~s
M ie a vdmkx.r 4 homestead interest, to collect the nests, Loam and
0xv of nosy tntiss, ale rests. inum, and proAts when m coUsetsd " to
tbs as h
1sr. si er seavv ag legal or eqattablo interest in the P( by
nut (by eumigasewt ei s.~
iwti f. Nmrmt et by a tins. Imsg►btat lease or m nay other way tin pe4 wsM~llp
6ataaem pgable under this Contract is first paid is fall or tMitlslss
ima ltirllps.irnrted hriwtrdor thin Contract solely as security tee a Ldimmdasreet
eextM a. smb er ewe~ass without Vendor's written eomesst. the osxRbxe
asriN bsmismm inmeN dw and payable is fail, at Vendor's eptloa wu-----
S??- tibi antis wbea due under nay mortgage oubtanding against the Property em do of
tbb (s.yPtllt sglwit by lnsebmssr) or under any note secured peevidsd revels t
tl pm~M~ at mlN..b wader tills Contract. Pnxhaser may make any suer now M
' Milt it lb de se and an Payrra se made by Purchaser .ball be moss
Time mq esmisM any dmI Il witbsut waitia8 any other subsequent or prior default of Paxbsnr.
AS hems of Ai4 d" be N~ilm~ open sold fame is the bensdb of the hake, btpi ;
r~ atN per'96 e. (It mat as owner of the Propety the spouse et ~indmt
~IsmmM~majim ~timommemmd rtgbtm i• the sijeet Property and agrees to join is !be
Doled 29th y October
SEAL .rye sra./...(23")
Leonard ...D. TUM David D. Tu>ml
-•-!slut.)
_.._..Laurie A. Tumor
i ' .....0 $ R !!4._ TOM...
w;
AVTZINUTICATION ACKNOWLSDGMZNT
(s) STATE OF WISCONSIN
err.
lCotraty.
errtbmtmd AU ANY of.......................... 119 Personally came beforit me this . 9th-_AM
October 7
.
Leonard D. Tu>:an
?~.i and.. Days d,~
T12W: KZ3Mltt STATE BAR OF WISCONSIN A. Tun[1o1
(Is tls-icedby f 06.06, WkStab.) to me known to be the
foregoing
* vitas INSTRUMM" IMAM maA MD NY
».t..D Petersen..... AttY-:_..8t._ mow... Bert
:_ifi"!f!M&..!S}._.140 Notary Public .
~tlk .
MW be tladmi or sasawled"L Both My Commission is • (i!l
ere irlR illieNmhr) date
,
b4sw
td!ft
'W Oak
y: .
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER BUYER Lsa"J t d LQuue_:Tac1n M
ROUTE/BOX NUMBER Q4_l -&J X go FIRE NO.
CITY/STATE t„r~e1`ci_Li.C 1A ) i's ZIP
PROPERTY LOCATION: _Z~V1/4 /4, Section Zl , T 3~N, R W,
Town of 7` , St. Croix AACounty,
Subdivision AJA , Lot No. 1VA .
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.Cro County Zoning Office within
30 days of the three year expiration date.
Illli
SIGNED ti 1LL"'" 1
DATE
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
' ' . }gam' _ y R ; T. T A ~t ~ D~7• '1.A t~r~
I
` Wisconsin Department of Industry , Labor and `Human Relations
-OFFICE USE ONLY Safety and Buildings Division FFICE USE ONLY
Amount Paid 201 East Washington Avene, P.O. Box 7969 Petition No.
Receipt No. 3 Madison, Wisconsin 53707 E-Number
6081266-3151
Name of Owner/ et tioner 9u1ding or Pro'ect Agent, Architect or Engineerin it
. :~Ld ^!`~r~,__.!~ t4 fn 3__J_'~'~"►.] rfite-#
Company Tenant Name, if any Street & Number
O /A N / A-
Street & Number Location, Street & Number City State Zip Code
81,66,Aenr S4 -7
City State Zip Code City County Telephone Number
Telephone Nuter Plan Number, if known - Name of Contact Person
1. The rule being petitioned reads as follows: (cite specific rule number and language)
-tea
Z. The rule being petitioned cannot be entirely satisfied, because:
3. The following alternative(s) and supporting information are proposed as a means of providing an equivalent degree
of health', safety or welfare as addressed by the rule: F
-e -kix_ ez t'
LCL'
s
Note: Please attach any pictures, grans, sketches or required position statements.
VERIFICATION BY OWNER - PETITION IS VALID ONLY IF NOTARIZED AND ACCOMPANIED BY REVIEW FEE
See Section Ind 69.15 for complete fee information
Note: Petitioner must be the owner of the 'building or project. Tenants, agents, designers, contractors, attorneys,
etc. may not sign petition, unless a Flower of Attorney is submitted with the Petition for Variance Application.
_Laurie A "him being duly sworn, I state as petitioner that I have read the foregoing
{NAME OF PETITIOta_fi,le,s.~ #:yis fprintj
petition, What I be lizae i^ and have s -anifieant ownership rights in the subject building or project.
f
Subscribed and sworn to before me this date 1?j
Sigr ~r
My commission expires:
T
? SB-Ei P R ~ 09/8$ i
INDUST MEN,YOF REPORT ON SOIL BORINGS AND SAFETY & BUILDING$
DIY)$
INDUSTRY, c P,O. BOX 714
LABOR AND PERCOLATION ; MADISON, W1637ff
HUMAN RELATIONS
R 83.09(2) $i Chapter 245
LOCATION: SECTION TO $1! UNICIP_ Ty: T
N/`/ IVE'I 21 /T 31 N/R /A (r) W
j
COUNTY; M ILIN PREW,
OATBS ~1b6 ATt:#1A{1E
USE .
NO, C E L D I N: ,
Residence UNevNi' '4ePI8Ge :'77
k"
RATING: S= Site suitable for system U= Site unsuitable for system
M ONVENTI NAL: MOUND: IN Fi0_ S -IN-FILL L fi1G AN 1;COMtW N Ei71 YSTEtiA:Itf~tionai)
x
IS u s ou 0S (u c s u s ❑u 64iNA..)
DESIGN RATE: r
If Percolation Tests are NO'Crequired q If any portion of the tested ar~.itF in the
under s. ILHR 83.09(5)(b), indicate: / •/A- Floodplain, indicate FloodPlairt-elevation '
Q Q ~Ovl' A~ It yiyll PROFILE DES"IPTIONS ~Q
'(1 /,q
EXTUR ,_At 1
BORING TOTAL DEPTH TO FIU DWAT I GH Hq A IL WITH TN KN SS, COLOR
NUMBER DO" IN. ELEVATION O S Rv To'I F 2jaMVER E"` RV. ON BA
:keg
g l oN /4/
Z"A
64
911P Ajj~ 94 6
_r%, A Si 0,
C)
r
.o r
a c J /t!. o't• !S'6 O w rlS.t+ SC+ - r
6-
PERCOLATION TESTS
IN
DEPTH WATER IN HOLE TEST I E WATER Pr4OPTN V RATE MM FES
NUMBER INCHES AFTER SWELLING INTER AL-MIN.' -_PERI01 t 516D2 44 01~
P T/ 46
P-
P_ G
/
Gf
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what we the ht
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 POfCa
of land slope.
SYSIF Ei.EVAT10 } f~
r
3
A '7
.
Nn, 5
~ i
B 3
v
r { I 1...,
elf,
I, the undersigned, hereby certify that the soil tests reported on this form ere made y me in accord with the procedures and methods splified inIt~10y{scona
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 WEFT 'CCM+lPLETEO ON: el-IN _ri?t
_si.1 CERTIFICATION NVUB£R: PHONE NUMBERf
A DRESS: ~
e),AL -7
S SI A
DISTRIBUTION: Qriginal and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395(R. 10/83) OVER
State of Wisconsin ` Department of Industry, Labor and Human Relations
PRIVATE SEWAGE PLAN APPROVAL SAFETY & BUILDINGS DIVISION
Office of Division Codes and Application
201 East Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
SYKORA EXCAVATING Owner: DAVID & LAURIE TUMM
ROUTE 2, BOX 75 ROUTE 1, BOX 80
BLOOMER, WI 54724 EMERALD, WI 54012
RE: Plan Number: S89-02264 Date Approved: October 10, 1989
Gallons Per Day: 450 Date Received: September 5, 1989
Project Name: TUMM, DAVID & LAURIE Location: NW,NE,21,31,15W
Town of FOREST County: ST CROIX
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 PETITION
- REPLACEMENT MOUND
Inquiries concerning this approval may be made by calling (608) 267-3605.
Sincerely,
DAVID RUSSELL
Section of Private Sewage
Division of Safety and Buildings
PPP011/0009n/ 3
cc: DAVID & LAURIE TUMM
-Private Sewage Consultant -County _UW-SSWMP -Plumbing Consultant
Owner Plumber Environmental Health
SBD-6423 (R. 08/88)
4
I
90 State of Wisconsin \ Department of Industry, Labor and Human Relations
SAFETY & BUILDINGS DIVISION
Oc tore r 1 2 , 1 `Jv 201 E. Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
i
I
Davi c! an!! L.iuri - l urnf,
Route I, ,ox eta
Useral o, k.rl 5401
Pr•tl'CiUri ;ti `:-lifl~4-P
gear tir. & ;rs. Turgi:
R-,: D, vii Laurie Tur)rr~ kesinence
Onsl tP Sewaoe Svst.ec,
NW,iuE, I,~1,ljw
Town of Forest., St. Croix County,
Section 145,24 (1), Wisconsin Statutes, ara s. ILhk 8.J1r (2) (L), Wisconsin
Aar!ni ni strar.i ve Corse, al l ov; tie owner to ber.i ti on tt)e oe0artIT*nt for a variance
tc, ttre installation for an onsi; , sewage to rerlace an existina onsite
sea,aaae svst~!?i at %A .,ice, wilier, is not in tull cor:l.ilr~ner with) the siting
stanr?arc;., in the aortinistr--~tivf! rule. The svster; (lesion l)rooosp.o shoula
orot.ect the waters of tkc- state f ron cont.aroi nati on, It this svstevi becunes a
tai 1 i na svstern or, contaminates tb(c eaters of thsr,atL~, tali s variance shall be
r(6SC rdPti; y
Thc: ;ctition for a variance reouestea to s. it-hp tI1 (d) of tle 61 S.
Adm. i'-~re wvaS consicereo can OCt:O!-)er .3, Tile Detltion tics )een oDDrove(l.
The, r1,le reciuires a ~;iounr., svstfr!i sit.; to have a i~iinitf,,ur~: of 24 inches of
suitai l- natural soi 1 .
Tne varl on, e reCU Sted was t.o i r)sta 1 I a r ~r : = cNt~ rr>r. rr,ouno, svs'recr, on a site
wi ti; 12 i ncl es of suitable nati..ira) sot i .
A!1 1 of the data and stateiii2nts sor ali ttea `.n behalf of t rt: GP_tl tl oner were
considered. ois variance is suecit1( tti the skjGie?ct. L'etirion and cannot be
i
usP(! for anv aamTionoI moritications.
Si re ref v,
Di recto'r', rutti ce of Di vi siion
Codes and AoDlication
I Is 'SP:.>1 15h
cc: LRr(,v L'ansl;v, Private Set atae consiaitar. - L1stri(:•. C, (Ihi Duer.a r=aI'Is
Trornas Nel sore, Loni nu Admi ni s c.rarc,r - . Croix (:our,ty
st-Ko a cxCavatt!i(l, P)uw-ber
SBD-6928 (R. 10187)
- - -
NJ
Perforated Pipe Detoll
0
End_ V{~w.
Perforated iReN to 4RhaE .L
PVC Pipe CNG MRR►cf. k`~~
End COP 1\j~' ff ~i '
j . ,°oce l ~~`4 ores Located On Bottom,
W • Qe~° h~ ~ ~t Equally Spaced
PVC •et,FAan
r`, t 'ri1~ h
From Pump ctt -.Cer
-o
E+tOCAP ~9 `PVC
Manifold Prpe
0-
Distribution
Pipe
r
Last Mob St+outd ee
Nest To End COP
Dislribulion Pipe Layout
i
x
Y
Hole 'Diameter 1 Inch
f
Signed: Lateral. Inch(es)
Manifold t304hnches
License Number: 'S
Force Main Inches
Date: Holes per pipe
invert Elevation of Laterals LDFt/E~►1r
-°9 ..d+ 11 rf
90 r{ t ,7t; 53 1{3 SG ' ~Gft J~ l~}lr _1:3' i! 4.70,
f
,L G. r 4.0.1 Q.~ r,,t`c3vu•~i T1b~u~
6/11
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k t i 7
1 Gi l2ll wi to i v i % i ( S
t .q S +w ~ ~ 1 'I
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t t'jrfl~1. !D l ~l a
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDhIST)Y, CC DIVISION LA60R AN
P.O. BOX HUMAN REDLA'TIONS PERCOLATION TESTS (11J) MADISON WI 53707
11 HR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHI UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
1V1,V,E V 21 /T 31 N/R /A ( r) W
I --I
r
COUNTY: MAILING ADDRESS:
1 1wr, EPA ira lj U)t" 5-41 1 Z
USE DATES OSSE VATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES9RIPTIONS: A STS:
JXResidence ❑New Replace I 7/Z5 6 / V
g-A~QCj
RATING: S= Site suitable for system U= Site unsuitable for system CI
CONVENTIONAL: MOUND: IN-GROUND-PRREESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional)
E:] S ®U ❑U ❑ S NU ❑ S U S ❑U a
If Percolation Tests are NOT required DESIGN RATE- If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), in iVA- Floodplain, indicate Floodplain elevation: N/,4
/Aa~ /r'a ,60,x. tf /Odum PROFILE DESCRIPTIONS PQ
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, ANO DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
6'C7"1LZ.94t- %,'1 178 Its
LIM is S
B- s TiT 9f, Z3 ~r~5y~rt Bw s; /rtgr j
/ ff-gffL,~ywt N ~iI ?s~ g f:/L'f B.. si 12 fr Z+O~'
B- /Qd S 5-0 ~ Z. ; loin rra - 8
13-
B-
B-
PERCOLATION TESTS
} EST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES
f NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- Z u Ica
P-
P_
P_ If .101 11 /
SOL,
P- N
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.
E
f
3
/Z7' `z
1
7 I
r
~N
t
k
f
lo P~
x
3 E j I F
t
t i if
i T
1
i
I
1, the undersigned, hereby certify that the soil tests reported on this form Were made me in accord with the procedures and methods sp ,tied in tl~ sconsin
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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(o tional):
Z o x l.*J ; ?l~'"' cif
CS SIG AT E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
L DILHR•SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395 -
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system:
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER
SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS:
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet
may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if
appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and yur certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL
AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Standstone
gr - Gravel (under 3") LS - Limestone
's - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Precolation Rate
med s - Medium Sand W - Well
is - Fine Sand Bldg Building
Is- Loamy Sand - Greater Than
'sl - Loamy Sand - Less Than
'1 - Loam Bn - Brown
'sil - Silt Loam BI - Black
si - Slit Gy - Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ - with
sic Silty Clay fff few, fine, faint
'c Clay cc - common, coarse
- r;
pt - Peat mm - Many, Medium
m - Muck d - distinct
p - prominent
HWL - High water level,
surface water
Six general soil textures BM - Bench Mark
for liquid waste disposal VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system
and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
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:
NW 4, NE 4f Sec. 21, T21-R15W ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Forest ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
F OL ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
David Tumm t.l Box 80 Emerald WI 54012
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:
John P. Sykora III 3312 St. Croix 128688
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: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
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:
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: 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 -411"
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
State of Wisconsin \ Department of Industry, Labor and Human Relations
-
Nt21 tfA_tL 'SLWAIiL F't_APl APf'R VAL SAFETY & BUILDINGS DIVISION
tM
l.i, l+rtx <d t
Y'E)itif~ %(tltNa,t
OU)!3W R, t41 :11;x.! 41t ,).Si}..
RE: Plan Number- S89-02264
~.t<: 1 hart`:. I''~Y }4ct:~~ [e~~,::; tf.ll t<, •'i'~.+tit.i, . :~r})('~'tl`f}?F'i' , 7`~`Iy
R1,lMM.. € tv<i..1 1±i,1''.1C. 141"1, td
}':.wo of F0R;t'.~} iy: .3i i };l~JX
ttie 1)111(lit i1) j j"idrt`_. Sri;.~ St)r=' !j Ir.:!tj iCi 1t7r }('t{'. }1rtY_}L'i'_i }ki r{ Ti V~ta♦nt,.j t<ir
Ifllf!II-fri1, Hdl).}1 }3~if7fQf;i4R w,<!~}(` rE'ifUli!'i11t`i;LS tlf~ 11;4.f poi. i i }1K;ed off ltlcip`er
Wit W,con, (1 h}'t
:A'vlpf-1 t,] [ Ionat Iv :jf))'r'.;vff1 ih',l of prl ont ;it')±llt ) 0MI)I I.:W--E., with
<111y ?I i'r{ft:.it 1;')fl', `.;}it)'v~(E t!!t' (:'i lf'1' lA i },i'541~ t`'_) cif r if il:= j [ili`,C tJ+' [t)rrF'C
t t ft-'tlil! l I okiL'.' 1 t e0 Ij1•; th, i'y, l I ~a j it)'rlrttl l tff,a `~f}:t ! 1 Itr UI:Yt%11(lti~
},~t'it>I iU f f,)rI`tj, jt)rl }Il+: t?C~ il~,'t~ Il~aa;l~!'T ti 5} ..?Sl: tI_ ii ~a'~i' }11~, s.;i:,t~tt idt"1Ctrf
'Ai Lw-t Vl'I tho d 1; ;i1 FinPf'ii (,1111}! alt ih't'
t:Ufi`,.,t-rll, No lle. }It` `f (1 `.ia}i(C' 1 (i^-?S1.11ii if",'' 1',l; 11it.f` m r,;ector inN:'(l
lrl`i}}!?; Llf)i?^, t:;?fi t3E FAarji_'.
t kl i d il) f Cl ka rl i w ! E H.' x j t p: t 'wr'f% i r } ; T11r1 ` 11t1" f l -i 1 7 2 1: CI r i ,:k t 9
fill:it `i }r£;'TEV1l 1'S ti{iidlrl'''.{, ji- qi E 1 } lT~ tttt' Ilay ,f ff?'a! i >ciial;-'t.T 1)f'(!fl!" YP rC'
ht" F' l }<311 ''1f i Y lifr#1. '0W;1 (;.jr e l'.'tr.?!?ti T „zt r.~1 ! 1... t tir. rW'M 1.
tt , ri irl tltl(+ #t,t}{ ` iT }<_'rit } i.~ :1t i a r, _ t
1 h .ipj)r'ov"v i i itf t h"
}}t'{if.l"f t@°`~ _+arc~'rr,1r~FE r}tt;, .aj}(:ilw;l} ti=l • fir:' ,i:c'Itlt` U+, i.;^.Pi,;?'J it.l.~t%i ~
irtCE"rr {y CIO R~iuE~
n ~T 1 .(7J
ZOWN ~~`._t;' .J•
t lif!`.~.iCti Y1} 4Yt tt t.ilti t?I
v f.
4,'Wi-U tdiii uf.' 'iw ',`,U}}' }'Iuftfl.~lily C(;ri`.U!t- fit'
',-.~fi~~; ; ,'l4?ll:)='€ i.1i:, ~11~7titll(c•ft~,~ ! ti~:'ci } tt;
SBD-6423 (R. 08/88)
- - -
SANITARY PERMI APPLICATION
151LHR COUNTY
In accord with ILHR 83. 5, Wis. Adm. Code
STATE SANITARY PER IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than !i
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 INFORM 10".
PROPERTY OWNER PROPERTY LOCATION
['~k JA 44"t IM
PROPERTY OWNER'S MAILING ADDRESS 4 LOT # BLOCK
CITY, STATE ZIP cC~ODE PHONE NUMBER SUBDIVISIONPNAME OR CSM NUMBER
dQtir'd~~ 3r6/i fj ~ Vol 'f ~A
CITY NEAREST ROAD
IL TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE --)r,-, A' 216
AX NUIVItStH(b)
❑ Public 1 or 2 Fam. Dwellings of bedrooms PARCEL
IIC BUILDING USE: (if building type is public, check all that apply) -
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ MedioAi Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 713 Merchandise: Sales/Repairs 11: ❑ Restaurant/BarJDining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A Check line B if applicable)
A) 1. ❑ New 2. Replacement 3."E ]Replacement of 4. ❑ Reconnectionof 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 N Mound 30 El Specify Type 41 El H' 61 Tank
12 ❑ Seepage Trench 22 . In-Ground: 42 Pit Privy
13 F1 Seepage Pit'- .Pressure Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SY$TEM' INFORMATION:
1. GALLONS PER DAY 2.'ABSORP. AREA S. ABSORPt AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (q. It.),.. (Gals/day/sq. ft.) (Min./inch) ELEVATION
lei
VII. TANK CAPACITY Site
in allons - Total # of Prefab. Fiber- Exper.
INFORMATION Manufacturer's Name Con- Steel Plastic
New stin Gallons Tanks oncret strutted glass App.
Tanks Tanks
frpf" S
Septic Tank or Holdin Tank 1 C)
J
Lift Pump Tank/Si hon Chamber 00 rJ A 8WI El I F-1
II'. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on t, ttached plans.
Plumber's Name (Print): Plumber's Signature: No S mps) M _/MPRS Business Phone Number:
Piu r'sAddress S t, City, State, Zip Cod l
e -7s 916 6 L d_ t Lij ~ -7
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssu T uing Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial g c'!s
! eft F
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD4W8 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCT14NS k
1. A sanitary permit is valid for tvKp.(2) years.
12 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 apptlicable.
3. All revisions to this permit must be approved by tha permit-issuing authority. ;1
4: Changes to ownership or plumber requtres a Sgpitary Permit Transfer/Renewal 'Form (SBD 6399) t ge , t
.submitted to the county prior;to ingtallation
5. ' Onsite.sewage .rsystems must be properly main lined. The septic tanli(i3) must beYptun ppdby
3pumper whenever necessary, usually.every 2 to 3 Years.
6. If you have questions:con- cer fng
.'o.fsitesevra a system, contactq ' sour local code.
- f Administrat6r-orttte
State of Wisconsin, Safety Buildings Division„ 608-26E);3813.'
To be complete and accurate, this sanitary permit appl)catn must include: ,'..i..
I. Property owner's name and mailing address. Provide *i4egs Aexription and parcel tax-number(*,of - -
where the system is to be installed,
_11. Type of building being-serwed.-Oheek only one afwt- "plete # of bedrooms if 1 or 2 Family DwelligQ; a: `s
III. _ Building use, If, ljoing type is Public, chvgk'al);ppi~roRriate,b ps.,that-apply.
IV. .'Type ofperm itf:> ftok orily one in line AzCpe>lpaa Mne Bjf-,p*mjt vf0.r,~ank replacement, recon.neotign;
trel#ir.; - c; . i :r t t
V. Type.ofrsystem. Chhe'al~ eppropriate box depending on SySt m tYAe
VI. Absorption sySteM iniorllPa'ti~n `Pt'ovt_~e.i3ilt°TnfoTr~tlt~ff regt/~t~'1(~#1'?"' ' v'" ~ °w T~^ ~
{(4,C.T., ti. '40 rH Ord i
VII. Tank information. Fill in the caPecity of-everynew and/br existing tank, list the iota( gaDons, 'numb,"r o
-tanks and manufacturerwharte vindicatd prefab br.siterzonsWitiad' and tat*vnaterial, Complete for stffr
1.9e10tfc; pump/siphon and holcUrg4anks for this systerroltlreelc experimental approvatRinly if tanks rrecdlvfrd
experimental product.approval, from DILHR - Y m 4 ,f ✓ , t
VIII. Responsibility statement instafiing-plumber Is tufitl M name, license number wtth appropriateprefix (e.g.
d
MP, etc.), address and phone number. Plumbef rrmst-sign application form. ;4sr
IX. County/Department Use Only.
c
X County/Department Use Only.
1: - f '
Complete-plans :and specifications, not.smaller ttian 8% x 11.Ikk%bs must be submitted to;tlie 66bM~r'M6-
t plans must himt1de the following: A) plot plan, drawn to scale or With complete dimensions, lob-aJ06 00-o'
i holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water, rnains/Water sdr i, I' I
streams-and• lakes; •pump or siphon tanks; distriau"ili o~tes; sail °absorptrar1' g; rata . system ; f
areas; and the location of the building served; B) horizontal and vertical if&=,f, 6jei'erfdef (rst
I
C) complete specif catians fo pumps arict cor-qtr W-Vobe vofoifle `$4evstidv- diif wen 4ricti~ losm pump
performance curve; pump rti'odel and puttt'tttlfacturer;'D} cross section of the soil ab prpt)on systefn4f.
rey> ! b the county; E) soil:tost data on a 11S form and F) all siz' information.
y..
.s - i {1M. < d
r urny r rMy iX 'GROUNBWNTER 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_use.d for monitoring groundwater, ground-
water contamination investigations and establishment of standards. - -
.
SBD-&%* (R.11/e8) _
ST. CROIX COUNTY
WISCONSIN
n ~G} ^3 ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
August 8, 1989
Division of Safety and Buildings
Bureau of Plumbing
P. O. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation of the David and Laurie Tumm property
located in the NW 1/4 of the NE 1/4 of Section 21, T31N-R15W,
Town of Forest, St. Croix County, revealed soils to a depth of 12
inches, after which high ground water was noted.
This site should be suitable for a mound system.
Should you have any questions regarding this subject, please feel
free to contact this office.
Sincerely,
Thomas C. Nelson
Zoning Administrator
TCN:sma
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & I3UtLQ1:d
INDUSTRY, OJ~f
LABOR AND
PERCOLATION TEST 115 0,0. Box,;
HUWAN RELATIONS MA{JIgENV Wt
' R 83.08111 & Chapter 145
A SECT N:'- TO .N£H: U 1GIl? TY: OT ST ~Fk NAME:
"s
MME% 2! /T 31 N/R
6T
COUNTY: IMAILINGAJODRESS.
y
r Ill
DATES 098E ATIOM
E
E 1COMMERCIAL S 1
)<Residence JNO. i / ❑New *@place.,
RATING: S- Site suitable for system U. Site unsuitable for system
MM>rN Y IYI fpp N
O
[IS N T AL: MOUND.nu IN.GFidUN ((9 S -1N-F,IrLL LDI G ANR r
rx~m
UC
If Percolation Tests are NOT required DESIGN RATE:
_ r~ If any portioni af,th® tested areesVs in the
under s. ILHR $3.0915i(b), indicate: r~J Fioodplain, irdiCaa~te Floodglaiii~IllYVatian.
Q MA Wow, si /04W . PRQFIL
Q 'C DESCRIPTIONS TctBARING TAL P H R N T INCH HARAOTIE R OF ST WIT 7H1 KNESS. COLq .1EXTUR9 AND,
NUMBER DEPTH IN, ELEVATION OBE V' ED TO Dko
tF Ep EE` AV. ON
B' ~ ! 9 ~ ~ J ~ ~ `r-•' N i[.. r~ • sw 1 ' ~ "i~' 'L. i~!'i,#` ~w f
r
B- /W ` S'/'.` l~^ t]Ii rh M S i ! Y / = Z3 "-J ~'t`/ 'i t► ; ~b iG
~ rf7„ b ~ ✓ E .
' a r'
B- c~ ~ X07"• ♦~'13"":E;pM' tSw, 5~C'.
F13-
TESTS
TEST DEPTH , WATER IN HOLE TEST TIME WATER DROP IN V H A
NISAtiER INCHES AFTER SWELLING INTERVAL-MIN.
PI~RIOC) t P 1 P IN N
P- 14 p
P. Z
k
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe v4#W are thb
zontal and vertical elevation reference points and show their location on the plot" plan. Show the surface elevation at all borings and the dinWioft sacl per,
of land slope.
SYSIEM EL
EM
- 4-.,-. j
I
I i 4
1
41 _ l
77
,
I
CC l
.
1
f_ rt , r -
I
i Pte; !
1, the undersigned, hereby certify that the soil tests reported on this torrtt v4e~ade
y mein acco#dwith the procldziyresattd methods sfied in~tcc>n
Administrative Code, and that the data recorded and the location of the tests are correct to the best of pW knowledger,#nd l>fief.
NAME print : ST WE t ETED ON'.
ADDRESS - - - - C,i~RTIFICATIC7N NUMBER; PONE N . . E
IG AT
DISTRIBUTION; Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10183) - OVER
i
CERTIFIED SURVEY MAP NO.
LOCATED IN PART OF THE NORTHWEST QUARTER OF THE NORTHEAST QUARTER OF SECTION 21 ,
TOWNSHIP 31 NORTH , RANGE 15 WEST , TOWN OF FOREST , ST. CROIX COUNTY, WISCONSIN.
R/W RI W
C~
NORTH LINE OF NORTHEAST QUARTER SEC.21. r
P.O.C. WEST 2660.85 33!....
984.58} 188 57' 1487. 70'•
q
• ,t
S .
1 ~ vs. •
„ I CZ a 1
02 00 WI I 33' S 02 008, 11 W
w
1
33.02 i P.O. & • ` I 33.02
EAST 188.57
R/W- R/ W
1 ~
N 1/4 COR. NE COR.
SEC. 21-31-I5. SHE CULVERT 1 SEC. 21-31-15.
~ I
LEGEND
rt DRIVE ,L O 1- 1/4 "x 30" IRON PIPE
N LOT X kco to " SET, MIN. WT. 2.271b./Lf.
° N 1" x 24" IRON PIPE SET,
=r, 0 43 995 s0. ft. o .-I ® MIN. WT. 1.13 Ib./I.f.
m ( 1.01 ACRES)
2"sq.x 36" IRON PIPE
SET,MIN. WT. 2.47 11011.,
dddd~~~~ v m z s WITH ALUM. CAP.
y. ro SEPTIC y E FOUND COUNTY MON.
BEARINGS ARE REFERENCED HODS 1
TO THE NORTH LINE OF THE h w w r-X FENCE LINE .
NORTHEAST QUARTER Of
see. 21-aI-1s.
(ASSUM[0 wcsT)
SHED ~1
SH 0 -
x X F z X x~ SCALE
0 25 50 100
1 " . 6o '
x ~
Dt~~l PREPARED FOR AND BY THE
DIRECTION OF THE OWNER:
f WEST 188. 57 ' LEONARD TUMM , RT. 1,
EMERALD, WISC.
'1N1',_A i ~:1) LAWIDS
SURVEYOR'S CERTIFICATE
I, RONALD F. JOHNSON, A REGISTERED WISCONSIN LAND SURVEYOR, DO HEREBY CERTIFY THAT I
HAVE SURVEYED, DIVIDED AND MAPPED A PARCEL OF LAND LOCATED IN PART OF THE NORTHWEST
QUARTER OF THE NORTHEAST QUARTER OF SECTION 21, TOWNSHIP 31 NORTH, RANGE 15 WEST, IN
THE TOWN OF FOREST, OF ST. CROIX COUNTY, WISCONSIN, DESCRIBED AS FOLLOWS:
COMMENCING AT THE NORTH QUARTER CORNER OF SAID SECTION 21; THENCE, ALONG THE NORTH LINE
OF SAID SECTION 21, EAST 984.58 FEET; THENCE S02008'111tW 33.02 FEET TO THE SOUTH RIGHT-
OF -WAY OF A TOWN ROAD, THIS BEING THE POINT OF BEGINNING; THENCE, ALONG SAID RIGHT-OF-
WAY, EAST 188.57 FEET; THENCE, LEAVING SAID RIGHT-OF-WAY, S02°08'1111W 233.31 FEET;
THENCE WEST 188.57 FEET; THENCE N02008'11t1E 233.31 FEET TO THE POINT OF BEGINNING.
CONTAINING 1.01 ACRES MORE OR LESS. SUBJECT TO ALL EASEMENTS OF RECORD.
I FURTHER CERTIFY THAT I HAVE FULLY COMPLIED WITH THE PROVISIONS OF CHAPTER 236.34 OF
THE WISCONSIN STATE STATUTES IN SURVEYING AND MAPPING THE SAME.
. 22
DATE G0 ONALD F. J SON R . L . S . # 1186
%
~ PRONALODNF.0 ~
00 NO S U R~ Js+y A"
RON JOHNSON ~t~IAb~SVRVEYING
P. O. BOX 176
BALSAM LAKE, WIS. f
(715) 48 5- 3300 I l