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HomeMy WebLinkAbout038-1083-10-000 C) 7 � 0 ® \ 0 \ / � � § \ k � k 4 . � g I / % z / LL \ /& . E 7 §2 # c _ E z z. z > . o R IL m C e g B z 2 ) z \ § z J _ c § z E k CY) 0 { ) -� § $ Q kco k .. } � { . c E k E � £ § m & k ) £ 2 t a @ ■ m ■ § # \ 7 § 2 2 d: di / - k a IL a ; CL « . j \ j § E $ $ E � A a \ a o )_ \ § _ E n % k # » M 4) 2 �0 ] E t \ § § q \ ) ) o tn ) z a ' � E d \ \ } § 0 z f / 2 / � © a k ƒ ) " CL a E & L)J a § Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT TOWNSHIP d I/OWNER uev"/ <�- SEC. T ,//N-R W ADDRESS �T/102 ST. CROIX COUNTY, WISCONSIN t JJ 1p SUBDIVISION �— LOT T SIZE PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM .34-11-11 s' r� iI ve 0 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used - o Elevation of vertical reference oint: p � Proposed slope at site: SEPTIC TANK: M4 u t(t P 4t.'2e_j- 5— Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front.0 Side, Rear, �`�/ feet From nearest- property line Front 10 Side QRear,O fee Number of feet from: well /$O / , building: (Include this information of the above plot pinxi)( ? reference dimensions to septic r;j r� 'T'RSE SIDE V PUMP CHAFER Manufacturer: 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, O Side, O Rear,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines: 9 Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,O it Vc> Number of feet from well: O Number of feet f rom building: (Include distances on plot plan). / Ile,..,�e r� Jo �.-► �f �G SEEPAGE PIT Size: Number of pits: Diameter: , Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil i 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, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: �'Z0 " Plumber on job: License Number: 3/84:mj anIV >r DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR & HUMAN RELATIONS P.O.BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,WI 53707 BUREAU OF PLUMBING S,N, W,SeC. 20,T31-R18W El CONVENTIONAL El ALTERNATIVE Srate PIan l.D.Number If assig Town of Star Prairie El Holding Tank ❑ In-Ground Pressure ❑Mound (r 90th St. NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Darrell Folie Rt. l Box 121F Somerset , WI 54025 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber. MP/MPRSW No. Coumy: Sanitary Permit Number: B ron Bird Jr. 3318 St. Croix 128655 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO ❑YES ONO BEDDING: VENf DIA.. VENT MATLL. HIGH WATER NUMBER{{ ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. FEET FROM LINE: AIR INLET: DYES ONO DYES ❑NO N DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY ]PUMP MODEL. JPUMP MANUFACTURER. WARNING LABEL LOCKING DYER PROVIDED: PROVIDED: ❑YES ONO ❑YES ONO I DYES .❑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 JMATIFHA_L AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH NO.OF DISTR.PIPE SPACING. COVER INSIDE CIA.. #PITS: LIQUID BEDTRENCH TRENCHES MAT RIAL• PIT DEPTH: t illmlg SIGNS ,5_3 � �� GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO. TR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES- ABOVE COVER. ELEV.INLET ELEV END. PIPES 7-0 AIR INLET: FEET FRCiM G 1 90,9.3 90, -7 7 2 3 INEARESr 6 70 o f 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- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER ITEXTURE PERMANENT MARKERS: OBSERVATION WELLS DYES FIND OYES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED: CENTER. EDGES. ❑YES NO ❑YES NO ❑YES NO PRESSURIZED DISTRIBUTION SYSTEM: �yy WIDTH. LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER $E : RENO TRENCHES: '. iIIIM�BISIDN3 MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. ID ISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELE V.. ELEV.. DIA.. ELEV.: PIPES. DIA.: tLfVA'TION ANO t711STR1BLiTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED RfiJIATIDN PLANS: ❑YES El NO El YES ❑NO COMMENTS: J j1tHMANtNT MARKERS: OBSERVATION WELLS flIUIVIBC*'R pF PROPERTY WELL: BUILDING: S -5 FEq-T-FR UI` V ❑YES ❑NO ❑YES El NO A1.EAREST IT 3 z I 1 Sketch System on Retain in county file for audit. Reverse Side. ' SIGNATURE: J TITLE: DILHR SBD 6710 (R.01/82) Ur `` SANITARY PERMIT APPLICATION =:Mh LHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY C r p STATESANITARY PERMIT# -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ I IF(0 8%x 11 inches in size. c eck ff revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. PROPERTY O ER PROPERTY LOCATION '/4,S O T N, R E(or PROPER WNER'S MAILING ADDRESS LO # BLOCK# � D e�- CITY,STATE ZIP CODE PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER 5 0� i II. TYPE OF BUILDING: (Check one) ❑State Owned VILLLLAGE NEAREST ROAD (p� f t e Q ❑ Public 1 X41 or 2 Fam. Dwelling-�#of bedrooms A EL Ax N MB O III. BUILDING USE: (If building type is public,check all that apply) —3 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facili 3(� 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ 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. LJ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an System ystem 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 El Mound 30 El Specify Type 41 El Holding Tank 12 9Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 El Seepage Pit Pressure 43 El 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 50 '-6/X Feet Feet • f VII. TANK CAPACITY f Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks I Tanks structed Septic Tank or Holdina Tank F1 F1 171 1 0 F71 Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: on 1 r 3-4 IT Plumber' Address(Street,City,State,Zip Code): c ^ �® IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved ;ritary Perm Fee(Includes Groundwater ate y�ue Issuing Agent Signature(No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial !_ Adverse D t rmin ti li�L X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will The applicable. III 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: I. 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. Vlll. 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. _ SBD4M(R.11/88) 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 a 1^h 17- L/ J <) l l -e Location of prop rty 1/ QjL�I/9, Section _, T -R-2/_W Township u"� a Aj',AJ-Jn2� Mailing address 6dj Lb / t Address of site Subdivision name Lot number —� Previous owner of property Total size of parcel 'g 14 Date parcel was created Are all corners and lot lines identifiable? /Yes No Is this property being developed for resale (spec house)? Yes 1�N0 Volume IMP C!;gC4 and Page Number 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 eed recorded In the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. ) • Signature of Owner Signature of Co- wner (If Applicable) �,�� � Date of Signature Date of Signature I • AS BUILT SANITARY SYSTEM REPORT Rt ��za. / f�� h' , TOWNSHIP Tu. r SEC. T41 N, g yT .j. ADDRESS , ST. CROIX COUNTY, WISCONSIN. 7; // wa to 3DIVISION LOT LOT SIZE PLAN VIEW -Distances b dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I N I ! I I � ;'TIC TANK(S)_L� MFGR. 's �e Ca sT CONCRETE }( STEEL Indicate Nanh AnnGW NO. of rings on cover Depth DRY WELL -,-ACHES NO. of - width length area no. of lines_ width d y' length a F-' area j�'a V . depth to top of pipe 33-E GATE / •..�.: RATE q AREA REQUIRED /S AREA AS BUILT �07 `/ ,riaimer: The inspection of this system by St. Croix County does not imply complete f•Dliance with State Administrative Codes. There are other areas that it is not possible -- inspect at this point of construction. St. Croix County assumes no liability for :tern operation. However, if failure is noted the County will make every effort to .-;ermine cause .of failure. '.:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST ~INSPECTOR DATED ( IW7 PLU;MER ON JOB C!� LICENSE NIJIMER—� 1 z REPORT OF INSPECTION_INDIVIDUAL SEWAGE SYSTEM San.itany Permit ' State Septic NAME rown.ah.ip St. Cnoix County �. Locat.ioA � Section� SEPTIC TANK Size gattonh . Number of Compantmentz Diztance Fnom: Wet 12% on greaten ztope it Bu.itd.ing it. Wettands fit• H.ighwaten DISPOSAL SYSTEM , D.iatance Fhom: Wet fit. 12% on greaten .6tope Bu.itd.ing wettands Ft. H.ighwaten FIELD DIMENSIONS : Width o6 trench it. Depth o6 %o chi b etow t.it e/A in. Length o6 each tine 6,Iit. Depth as hock oven t.ite� Num6en o6 tines Depth ob tide 6eZaw gtcadd .in. Totat Length ab tinez 6t. Stope o6 trench in pen 100 it. D.id Lance between tines [y it. Depth to b edno ck. � fit• Totat abso&bt,ion anea�4t2 Depth to groundwater �/� it .. Requited axea it 2 T yp e a b Coven: Pa en o raw PIT DIMENSIONS: Number ob p.itz Gnavet around p.it�s yea no Outside d.iamete 6 Depth below inlet fit. 2 Totat ab�sonbt.i ne t Z A 2 Area n quited it R' INSPECTED BY TITLE APPROVED ,DATE 1971 REJECTED , DATE 197 . State Permit # O o PLB 67 State and County �j � Permit Application �--�� County Permit for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED 7��l�,� Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: < /4 '/4, Section T3_N, R E- (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village / r Township .� C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms 7 No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CrCITY Total gallons No. of tanks Prefab concrete 1( Poured-in-Place Steel Fiberglass Other (specify) New Installation _ - Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. New, Z' Replacement Alternate (Specify) Seepage Trench: No.of Lineal Ft. jc Width Depth Tile depth (top)�_No.of Trenches Seepage Bed:-_Length -��Width " Depth 36 t( Tile depth (top) / No.of Lines Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits Percent slope of land ,�°is Distance from critical slope WATER SUPPLY: Private Joint❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, 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 Cer i ied Soi! Tester, / _ NAME C.S.T. # � - -;2 and other information obtained from �GJ�Lk �. ��R�witeer/builder). Plumber's Signature MP/MPRSW# � - Phone Plumber's Address / PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. i i y......P,. t m [ t € k tea.. ... f L ll / $ E E 6 t E j(��V i 1 VY / m a 3 t E r i { 3 E .. _. ... .. .m.. F � c t 1 i k Do Not Write in Spa c Below F R COUNTY AND STATE DEPARTMENT US ONLY Date of Application C - Fees Paid: State Co y O Date - Permit Issued/f (date) _ - Issuing Agent Nam Inspection Yes No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink c py) 4. plumber (canary copy) Revised Date 7/1/78 PLO B 6 7. State and County State Permit # �� Permit Application County Per t # for Private Domestic Sewage Syste s County -� *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: S,�� '/ '/4, Section 0 , TIL N, R L ♦ (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township YX,,, C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family _ Duplex No. of Bedrooms 3 No. of Persons _ D. SEPTIC TANK CAPACITY©CIO Total gallons No. of tanks / HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete_X- Poured-in-Place Steel Fiberglass Other (specify) New Installation _ Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area G is sq.ft. New Y, Replacement Alternate (Specify) Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches Seepage Bed: r Length,-Width 7 S z Depths-Tile depth (top)_�2No.of Lines -j Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits Percent slope of land % F. Distance from critical slope WATER SUPPLY: Private 0 Joint❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: 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 Soil Tester, NAME I, h � t4 ell We I(( S a 11 C.S.T. # S�'- 1 1 y 1 and other information obtained from v., G (per/builder).5� Q3i Phone #c;) /` Y -,3 � Y 3 Plumber's Signature % C ; w�.�, �� MP/A4F-"W# Plumber's Address_l� A Y 3 '> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. E ° s j t i i E E _ i ' t W l lu�ill bYC"v �S' ate.. . y.V ®n . 4 a f 3 E 5 t 4 i . .. .. ..n. .. ....w=. �.. .. .�... mw ns .. 3 E a 'A AcX 36c,� ' 5 9 r a t3 i 1 • .k a.m. zm.-. S t { t ' �w 3 # t 7 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USEPNLY ^ Date of Applicatiorn C- Fees Paid: State�C' Coun Date - Permit Issue re (date) 4_7 Issuing Agent Nam Inspection Ye State Valid# Date Recd 1. county (wy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 W015 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH P.O.BOX 309 MADISON,WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION:< _U'/4,P_AJ/4,Section,-rkN, R/J--E (o Township r Mdnicip-Litac..����� �Q9�Q�• Lot No. Block No. County Subdivision Name Owner's Name: Mailing Address: 97o c`1 �®� -y""" �' r~<<"u ))4,t et J.p 0 Z TYPE OF OCCUPANCY: Residence No..of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT C DATES OBSERVATIONS MADE: SOIL BORINGS / O ~ a-2 2 V PERCOLATION TESTS /a SOIL MAP SHEET 3 PP—9 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 NUM- INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN BER P_ a �/U 3v / P-3 30 r• �(1vv /U l �(o /��' �`� 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) /ha�iG - $C it 5. 1>6 C G t -7— 3 — 57.l N&A.G^ —oZ S G o - q Bc- 9_3os 3o-CvG S � � PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitab areas. dicate number of square feet of absorption area needed for building type and occupancy. Indicate scale or distances. Give horizontal and vertical reference points Indi ate slope. k tN d 4 ' O ✓���G OL I �v 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 location of test holes are correct to the best of m knowledge and belief. Name (pri Address ' -`) f ��� sGw Certification No. �-�^ Z �Z G/t 5'y/SZ/Z /�/0� Name of installer if known CST Signatu COPY A— LOCAL AUTHORITY 9 . � p t T � Akk M STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 4OWNER/B YER ROUTE/BOX NUMBER /' 13 °�` d /' FIRE NO. �� J CITY/STATE S`C" ­*. h J.PrjL L J 1'.e C_ ZIP J^ 7 �^ PROPERTY LOCATION: .S 1/4 /t/ f-J /4, Section 0 0 , T_2j N, R / W, Town of Xa ,/�tip �— , St. Croix County, Subdivision �'' ��� , 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„�C �-u�' DATE 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 3 ydP DEPARTfAENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS R 83.0911) & Chapter 145) LOCA ION: SECTION: WNSHIt/ NICIPALITY: t OT NO.:BLC NO.: SUBDIVISION NAME: W12 2o /T N/ e'.A,, — — MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMER IAL DESCRIPTION: A N TESTS: Residence ❑New Replace /–3_ r —1 RATING:S=Site suitable for system U=Site unsuitable for system Ct / Ile r ONVENTIONAL MOUND: IN-GROUND-PRESS SYSTEM-IN-FILL OLDING TANK: ECOMMENDED SYSTEM:(optional) s EZu: s au [As ❑ REas u E 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),indicate: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) a 0 .5?. B- v2 u o-•e. d ©—$ B- C 21 qf- B- B- PERCOLATION TESTS } T TH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES f NUMBER AFTERSWELLING INTERVAL-MIN. -PERIOD 1 P RIOD2 P R PER INCH P- o-,.c t4 j P- P- / S 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 $ E E � E E r € d4 I zd i ..� � N i Atli X3.1 Q . � I e E 3 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: n rte/ r. 97 ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional): o � .S o0 3 7 �G• '7 � CST SIG A E: ... DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) –OVER – r INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 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 yourtest locations.Drawing scale isprefered.Aseparatesheet 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 fs — 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 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. FLU I FLAN 'PR®�e�,CT �r,�rc/I ,�y� G ADDRESS ff ��cr c. ,5-qa�S' ,,; 1/4" 1/4/Sv-30/T,3/N/R`�5W TOWN COUNTY MPRS Byron Bird Jr. 3318 DATE — BEDROOM3 CLASS PERC -27-- CONVENTIONALX I -GROUN ESSURE CONVENTI NAL LIFT_MOUND_HOLDI G TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE IV HOLDING TANK SIZE ABSORPTION AREA ,9 6� PERC RATE �/G BED SIZE 111h, Benchmark V.R.P. Assume Elevation 100' Location of Benchmark �✓ Ga .� * H.R.P. --- O Borehole Q Well Scale Feet O Perc Hole System Elevation 7} Uent 12" Gradp TYPAR COVERING /]M 12" 3' 4 6' (D 3' 3' O 3' 1 6. Sewer Rock 12' 18' 1 gIce- P� 3p � I f