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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP V\ SEC. \Y T 2L_N-R L W
ADDRESS p~C # 2•~Z ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT _ LOT SIZE 2- A
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Poor k Loay AAA Lod ~7
Sys to ev, Ekv. /oo-s '
A B-M. C' lot ptV~-- S.E- cor„s( flV.= loo.o'
S1a\a- 10
w/ S i slop ~ ~a st
18~ . S
41
i
~ 'Yo
52
d
o s~o r'- _ ~ , W
s
qt
MOUSE GARAC a 2A•!v3
2 4fx -3.2,
o . Jos
A .
a i
a
_ INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used lo~• P;o~ 5.~, Lor.,Q,r
Elevation of vertical reference point: loo.o' Proposed slope at site: Ste Eases'
SEPTIC TANK: Manufacturer: We Sa.J Liquid Capacity: )-2.So qa.~
Number of rings used: Tank manhole cover elevation:
LS-
Tank Inlet Elevation: 3-qn Tank Outlet Elevation: Al-30
Number of feet from nearest Road:
Front,OSide, Rear, O feet
From nearest property line Front,OSide,~Rear,0 SS, feet
Number of feet from: well S 9~ building: Z I~
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SF.F. RF.VRRSF. RTnF
r
PUMP CHAMBER
Manufacturer: N4 y Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, 0 Side, 0 Rear, Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed : C_a n VrttZo. Q Trench
Width: j g Len4fh: 52.E Number of Lines: 3 Area Built:y?! 7
Fill depth to top of pipe: y0
Number of feet from nearest property line: Front, O Side, G Rear, OPt . 417
Number of feet from well: 9 2
Number of feet from building: (0 3
(Include distances on plot plan).
SEEPAGE PIT
Size: IVA Number of pits: Diameter: ,
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box0 been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, 0 Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: License Number: P
3/84:mj
w
APPLICATION FOR SANITARY PERMIT
S T C - 100
• DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
° 'tABOA & 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,, NE , S16, T29N-R19W 27 CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Hudson Holding Tank ❑ In-Ground Pressure El Mound
O P R: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam Miller Box 282, Hudson, WI 54016
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:
Doug Strohbeen MP 5432 St. Croix 119462
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
C PROVIDED: PROVIDED:
S 0 t 43 P .YES ❑ NO ❑ YES *4 NO
BEDDING: VENT DI A.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
I~~~~ ALARM: FEET FROM LINE: AIR INLET:
❑ YES L-NO ❑ YES &kNO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO [__1 YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
i PUMP ON AND OFF El YES E] NO NEAREST 00-
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.)
r, CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
O TRENCHES: MATERIAL PIT DEPTH:
DIMENSIONS S (p
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
:
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIP : LINE: IAIR INL T
FEET FROM -7
/_tl 4 ~*~IC Ol f c NEAREST ---00' q®5
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:
~
(I I ❑ YES ❑ NO ❑ YES ❑ NO NEAREST'
_B ,9r crif-
3 ~ . / b ~ n ~ ~ ►~~c~-cam x{,17
Q
Sketch System on Retain in county file for audit.
Reverse Side. SIGNA TITLE:
C Zong Achninistr
SBD-6710 (R. 06/88)
.
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k Ct Of t Quarter of Seatias 16, TatisfAip"29
mi-Ilw tYe Nismala QCRPT Lots 1 t4roY~i1 4, , 11
, !'!li . file ri•,_July 23, 1964 In Vol. "S", Pqp 14471,
. noa.:No.
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coat to tb Dealasatift of h+oteatIVO Co'018042te dated lebrua
t6axoff!"e:Of tba.MSlater of Deoda an 1rb . if6S, sraa
Ile. )l1r06. X1'7 18, 19SS in Vol. ` 706; lap . ,
"t to sfsw"xcluf to of "and for ttea of the 66 foot
y s+oad ,
srtlosed
Certified SurMep MsP. iieet
~~q t1SYl~,itlos teoaa
r~ t ktof test betwett Uw State of Viaconeis• H 7
YA ifs'2i; i 'Vol; « ad %O1W Firs dated SWtsAer 15, 19799 Mai 30
the !w►ea `b"twfs fire SM, of -SSA POP
a. .
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Sa Yt. 11~! ~6y -
ROUTE/BOX NUMBER T~nF Z~ `Z i FIRE NO.
CITY/STATEJ5ov-- ZIP y~e
PROPERTY LOCATION: 1/9 ~ ~c! 1/4, Section , T N, R44
Town of a , St. Croix County,
Subdivision nv , Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED 22
DATE y 7 y
i
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: E SECTION u/RD/~~(or TOWNSHIP OT NO.: BILK. NO.: SUBSI~ SI//t ONN'ME:
/ ~?1~
1 1 d/s oit,! 7 l y &M 4OUNTY: O NER'S BUYER'S NAME: MAILING ADDRESS:
.s . Onaii~ S e 8r k A sou GcJr' . s Yd/6
USE DATES OBSERVATIONS MADE
NO.BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLAT ON TESTS:
Residence 3 X New ❑ Replace V
RATING: S= Site suitable for system U= Site unsuitable for system (r- 5_4f ur 1`- 1161 Ca.y. e
CONVENTIONAL: MOUND: IN-GROUND-PRESSUR_E:SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDEDSYSTEM: (optional)
®S ❑U ®S ❑U ®S ❑U ❑S ZU ❑S ®U
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the n
under s.H63.09(5)(b), indicate: / Floodplain, indicate Floodplain elevation: Al
PR FILE DESCRIPTIONS
BORING TOTAL$ DEPTH TO GROUNDWATER 1111::66 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH +id ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / -7S' /03j" A16 7 7•s' B// . 7 AA / 6h 15 S. S Bn 11e
B- 2- 7,S- la q.(?' gme- 7 7,S' B/l , .SBA / ,SBn /S s- ed S
/03.7 ` o 7 . s" 3 B/ , S,gA l , 3 B /S S: joo' 8,? NtQd A
B 7,S' 66.2' 6 All- K l Bn s S. me S
3 By~r /Si
C? 6 /1 7 An ~ q •zV e d S Bsr :57/,
B-J ~.S 06. fL 7 7 S .
B-
PERCOLATION TESTS
TEST DEPTH) WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER MWhk"' AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD 3 PERINCH
P- / 3.3' 0 2 6 6 3
P- Z y 3` 14,10 z 6 4 4-3
' a .2 L 3
P- -3 AV
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.
qir
SYSTEM ELEVATION
7 46
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doruel 0A.!
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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:
P-V
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
C ATURE: r.
r
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING; FORM 115 - SBa - 6395
To be a complete and accurate soil test, your report must include:
1. Completr ' al description;
2. The u o nust clearly indicate whether this is a residence or commercial project;
3. MAXINy number of bedrooms or commercial use planned;
4. Is th;, E, or replacement system;
5. Co ti-Ie suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
O-`- _ SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
0. PL < . k: E use the abbreviations shown here for writing profile descriptions and completing the plot plan; ~
7. MA- , LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
sheet may be used if desired;
8. M your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Coranlete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain, elevation) do ~illy, place N.A. in the appropriate box;
11. Sign the form and place your current address and your cer-lcation 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 - Sandstone
gr - Gravel (under 3") LS - Limestone
s - Sand HGW - High Groundwater
cs Cc id Perc Percolation Rate
med s - f'Sand W Well
fs Bldg - Building
Is - I ~ ld Greater Than
' sl Sandy Loam - Less Than
'I Loam Bn - Brown
1,0 Silt Loam Bi Black
si Silt Gy - Gray
~cl Clay L( ; Y - Yellow
sci - Sin `v Loam R - Red
sicl - Silt C`.. )am mot - Mottles
sr, - Sat-, w/ with
sic - Silty Cl fff few, f,,
c -C, y cc - cornet
pi_ mrn - Many, n
rn d - distils`.
p - proxnine
HWL - High vva level,
le, soil sul ai..
~ ~rirf Vvaste { ~ posai BM - Bench
VRP - Vert ice Point
TO THE OWNER:
;t is lily sT p in r -init. The county or r,._yrequest
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A, '(,e 7e private
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