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`DEPAR131ENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
iSABOR&HUMAN RELATIONS DIVISION
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
MADISON,WI 53707 State Plan I.D.Number:
SE 4iNE,;,,Sec. 23 ,T28—R19W ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Troy ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
_. IT ADDRESS OF PERMIT HOLDER: INSPECTIO D T :
Richardson Farmer Rt . S 804 Chapman Dr. River Falls WIj6—,9(07Aq o2106
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:
Paul R. Cudd 2739 St . Croix 128691
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
4C PROVIDED PROVIDED:
d( AYES [__1 NO DYES LINO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH^ ALARM: FEET FROM LINE: AIR INLET:
❑YES I�10 '4 ❑YES ®NO NEAREST---* --
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
E]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—1110-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: I 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
DIMENSIONS TRENCHES: MATERIAL: PIT DEPTH:
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.D TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BE1LOW PIPES: AB/O�V/E.�COVER: ELEV.INL T: ELEV.END: C� PIPES: LINE: --t G AIR INLET:
FEET FROM(P`1 oCtiJ 941 ?l Q�{•35 ���1 NEARESTT�� �J'� IJ 8}
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 j 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
COMMENTS' PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF IPROPERT Y WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST-
�� �
79 $
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Sketch System on Retain in county file for audit.
Reverse Side. TORE: TITLE:
SBD-6710(R.06/88) z7onin& mid
to '
SANITARY PERMIT APPLICATION
rC91LHR COUN
In accord with ILHR 83.05,Wis.Adm.Code
STATE SANITARY PERMI, #
—Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /� �� 9/
8'fl x 11 inches in size. h i rev sion 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 OWNER PROPERTY LOCATION
Richardson Farmer SE % NE %,S23 T 28 , N, R 19 J""W
PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK#
Rt . 5 , 804 Chapman Drive ---------- --------
CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
River Falls , WI 154022 1(715 ) 425-5945 ----------
Check one) St O CITY NEAREST ROAD
( ate Owned VILLAGE
II. TYPE OF BUILDING: Tro Cha man Drive
❑ Public Ell or 2 Fam.Dwelling—#of bedrooms PARGEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public,check all that apply) 040-1087-80
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
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. ❑ New 2. ®Replacement 3. ❑Replacement of 4. ❑ Reconnection of 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 ❑ 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 1 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) 1 93 . 7 ELEVATION
450 900 900 0. 50 2 93 . 3 Feet Feet
VII. TANK CAPACITY Site
in gallons Total #of Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New istin Manufacturer's Name
Gallons Tanks Concrete stCon- glass App.
Tanks Tanks
Septic Tank or Holding Tank 1 X
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name(Print): P be s Signature: St MP/MPRSW No.: Business Phone Number:
Paul R. Cudd IMPRSW2739 715 425-2r9
Plumber's Address(Street,City,State,Zip Code):
Rt . 5, Box 364 , River Falls , WI 54022
IX. COUNTY/DEPARTMENT USE ONLY
��j� ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issu'ng Agent Signature(No Sts,
, A roved Surcharge Fee)
_l pp Owner Given Initial �6 �f,,,,_!�
Adverse Determination (1 [ 0
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,P'
� T
INSTRUCTIONS �^ •
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6_ If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
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.
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VIE. 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'A x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimen!;ions, location of
holding tank(:,), septic tank(s) or ether 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
performirl,ce 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 U'lisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated pr wf.ices which can effect groundwater.
-tie monies collected through these surcharges are; need for wot iitoeing groundwater, ground-
ter corrtaminafi(:an investigations and establishment of standards.
SBD-6398(R•'
S
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U1S;�lt'3v5��IJ Pl�e �v 6� �T L-1=�$T ZO )►JC1�ES FiELOw oR1G1iJ7 1 GP-ADS
c1�� ftT LERST ZO f1JCl}SS 8v1 1J0 Vl'D'ke`R}fi1J LJZ lkazxi S $CAW T1N1�L G(2JtD`!
p�lAXlt-�Ut'-1 DEP�i OF EXCAU}��O1J �ROt-� piZt6lfJltL GrRD`. �tL.L 13E 3Z ]NCH ES.
M U" b`P7?1 OF EX C:A VR7)ON =P-r.,1 CO12.1(S1 N)�L aTt^bE _1,U)L L $ 30 /K)CJi tFS
�! 5` ►�0. : MPRSW2739
-ter October 17 , 1989
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 Richardson 0. and Helen A. Farmer
Location of Property j 9. 14 �(F. ' , Section T__g2ff_N-R_LL_ W
Township J 6 B y
Mailing Address R1 L�a Jj-G
Q RIP,e
�
Address of Site
Subdivision Name -----------
Lot Number -----------
Previous Owner of Property 7jenne
Total Size of parcel -------------
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes _ No
i
Volume 4 and Page Number 0,2 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTY OWNER CERTIFICATION
I (We) cati.6y that at t .6tatement6 on this jotm ane ttue to the but o6 my (out)
kn.ow.eedge; that I (we) am (ate) the owner(.$) o6 the ptopW y du cAibed in thi.6
.in6otmafiion Sotm, by viAtue ob a waAAanty deed teco&ded in the 044.iee o6 the
County Reg.i6tet o6 Deet(aas Document No. 309 3 98 ; and that I (We) pteaentty
own the ptopoeed site Got the .6ewage diapo�s ayes em (ot I (we) have obtained an
easement, to tun with the above deaeni.bed ptopetty, bot the con6t)tucti.on o6 said
eyatem, and the tame has been duty recorded in the 046.ice o6 the County Reg-ibtet o6
Veede, as Document No. ) .
SIGNATURE OV.OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
October 16 , 1989 October 16 , 1989
DATE SIGNED DATE SIGNED
PAUL CUDD & SONS, INC.
1047 S.Wasson Lane
RIVER FALLS,WI 54022
(715)425-2049
Wis. License: MPRSW 2739
Our Specialty is taking care of your sewer system!
Date Feb. 3 1992
Name pick armer
Address 804 Chapman Dr.
River Falls, WI 54022
We're your Septi-Cleer distributor.
DATE
Description AMOUNT
1/31
65. 0
Mark pumped septic
15 . 0
1 bottle Lenzyme
State & County tax
. 83
TOTAL. 80- 83
Terms: Due on receipt
1i/2% interest per month on unpaid balance Thank You!
N_ 28210
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to and with the
rvir��r of t1;� n,, his :�r 11er heirs ,r:d assigns, that at tic trm<, of the c';:S0."! ii c,rr;i (, ti.�,1 of
well srvzcd of the
vs of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and
that the same are free and clear from all incumbrances whatever.
rr r ':at the above barn itined premises, in the quirt arm' pcai�eahJe possessir,n of thr s::id poi
;nt7( ,t;.i and cv7' cr ., or perj�cvr% f!1, 7s'. >i' a-
ro
f Diu „i:l forever V'.,I:Ff,, ` T
the .,r.;cl osrt � :: „{ .r r.;? ,rt lul .c, !e,Zo �ntri ,;r , 71.,-
._ ., p i117i , .� ?: ,
;�'•1 t'7i'+ (!cly of 1)r C, 1:1 l�7 l9 it
Si 7rcd, Se "^ 1 ::rtd :tcliver-2 i,-) pro3ence of
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i'�"uiary Fa^tic., � r- _r7i•�ty. ?�'rs-., _;r7.
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'itato of W
County of St. Croix
1 hereby certify that o this i
of the document on file
and of record in my
true and�� copy office and has been
compared by me.
Oct. 16 , fig 89
fittest -
James O'Connell
Jeswi d Re9wer of Deeds
Deputy
Form No. 105 H
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SEPTIC TANK MAINTENANCE AGREEMENT
St . Croix County
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OWNER/BUYER Richardson 0 . and Helen A. Farmer H
Rt . 5
ROUTE/BOX NUMBER 804 Chapman Drive Fire Number 804
CITY/STATE River Falls , WI ZIP 54022
PROPERTY LOCATION : SE ?�, NE _4, Section 23 T 28 N , R 19 W
i
Town of Troy St . Croix County,
Subdivision -------- Lot number----- •
Improper use dnd maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists 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 treat-
ment stage in the waste disposal system.
St . Croix County residents may be eligible to receive a grant for
a maximum of 60% 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 n_e_w 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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary) , 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 .
0
E
I/WE , the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth , herein , as set by the Wisconsin Depart- b
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning ffice within 30 days
of the three year expiration date .
SIGNED
i
DATE October 16 , 1989
St . Croix County Zoning Office
54015
715-796-2239
Sign. , date and return to above address .
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSkrt'Y, DIVISION
I A13013 AND PERCOLATION TESTS (115) MADISON W 53707
HUMAN RELATIONS
(ILHR 83.0911)& Chapter 145)
LOCATION: SECTION: TOWNSHI UNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME:
&E-1/4 NE 1/ z 3/Tz8 N/R Ia E to -T-�\ y — —
COUNTY: 43"IJ MAILING ADDRESS: 8oq c"PPIPIX3 Z)g -
'IT. C-km1X TRlct- N?--b3W FRR►, l~R S AQtFR L.LS, wI Sv0zZ
USE DATES OBSERVATIONS MADE
NO.BEDR : COMMERCIAL DESCRIPTION: .
Sesidence -� _,�_ ❑New Replace O- 8 Ct ti V_ �Z_8 9
RATING:S=Site suitable for system U=Site unsuitable for system l
CONVENTIONAL:. M ZS.E]U IN rat S Ou E: STEM-RILL HO11 S , TA K:RZECO MENDED SYSTEM:(optional)ce ,>.L .1 O I
If Percolation Tests are NOT required DESIGN RATE: If If any portion of the tested area is in the � �•
under s. ILHR 83.09(5)(b),indicate: N•R- Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- 66 q S- S )vo>J L __7 (.8 P)Pvr Z 6f= Z
B-
B-
B-
PERCOLATION TESTS
t DEPTH , WATER IN HOLE TEST TIME D WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. I p t PERIOD 2 PER INCH
P.
P. Z 30 vv0 3 0 -W s 13116 3
P- 30 �Ua �o l 3 ..
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. O C1 3•-1 �P1 b 8% V1 i"MPO> AS _Z C 'r11N1
SYSTEM ELEVATION y 2 3.3
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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.
WFGF13FR S011 TESTING
NAM (print): AND TESTS WERE COMPLETED ON:
DESIGN SERVICIF 10--1Z-SCj
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CsT ouo s'76 -)1S-U2 S-Ol6S
NAT :
RE �
j RIVER FALLS; W154022 L��CST SIGi a(
715-425-0165 /.
01= Z
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHRSBD6395(R.10/83) —OVER
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SOIL DESCRIPTION FORM
Attach So I P o lo L ca io a On a So aratf Shsst
lC s R Y'I
LINE L MG TE:
Pos :.�vhLv �RSoTt,PcaSO .P110N Sys oP
UZ L, I�JEG�1 nSPEC s�v`t-6}
DnE IPT[ON BY �f t2
�C ��•Q 1� 1 RENT ANO US
DATE.
COUNT /Si T : ST•
c ip tX VEGET TIV COVER G g
— — SAC,Z.3,Tz$N 19w oRAtNACE cLASSc
LOT pESCRIPTION:' T 6}' S U.SO
IV
C.�J GALLONS-MRS .V. PER DAY, Ck1 tY`} vT l s
LOCATION* "ftv;,dm hFSr C-��1�1 L Lo'r
SOIL SERIES,
PARENT MATERIAL s /DEP7 ••oil class flUumb.—
HORIZON DEP[11 MATRIX COLORS MOTTLES TEXTURE GSTRUCTURE Sh CONSISTENCE CIAYSNGSS/ PORES ROOTS PII •80UNOMY REWIRKS
in. nn s►
OY- 10 G
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OTHER SITE FEATURES/NOTES: �J � !r/ �D-�2_8 f ooaS7 6 Z
dllr 'yGG' n/1 GH,�,,, of 2• I
Signature Date CST N
LIMITING FACTORS/DEPTH:
J
San. Permit No.
£a:zer Is name
H63.05 PLOT PLAN
Show:
10 Dosing chamber
Location of building served N H g
C2 Vertical/horizontal reference point
'D Septic tank
ElBuilding sewer System elevation is Z �13• � _
Effluent system Well
�.1) Replacement system area\. Q
Property lines w/in 50' of system
Scale = 1�l���.9 or dimensioned
Q Distribution boxes f �!
NPR Pump and controls:
Mfr. & Model No. Vertical Lift Size Force Main
Friction Loss T. D. H.
Vol. Dist. Pipe Gal. .per Min. Gal, per Cycle
Place check mark in appropriate box, indicating item is shown on plot plan,below:
Eta luo.o W
C.(yV cl2e-Tr FLOM hT UOARR
�jC lS`PN G Se41�C - �aNv 3'c.
/ 30 of yN cr
cr"'J'� czEINE S e�%1n c Tyt�
y Z
3
3 °l0 "
0 S1
1Z?c.�57)N G nS ;
a�.►\�N Frio ! 2 q o' �_Z.. finn✓
7 2,0°Vu
By the granting or approving of the above plan, or upon the event of a subsequent
permit being
issued,St.CroixCounty and theSt.CroixSounty Zoning Administrator, does
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
aft nstallation.
MPRSW2739 October 17 , 1989
icense o. a e
P um r s signa ure , . 3
Y AS BUILT SANITARY SYSTEM REPORT
MEN
tER41�'C �'ds�� FQ rm-er , TOWNSHIP_ SEC. 0. T No R ,� W
0. ADDRESS e fig' . _ , ST. CROIX COUN Y, WISCON
Fr A Fq
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BDIVISION - , LOT LOT SIZE
PLAN VIEW
-Distances dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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I 'di Cate North; Azrola
SCALD .
tPTIC TANK(S) MFGR. CONCRETE STEEL
! N0. of rings on cover Depth DRY WELL
)"INCHES NO. of width length area
no. of lines S width length Yt '` area /S'_
depth to op of pipe _ •
AGUGATE
3' K RATE / AREA REQUIRED AREA AS BUILT __
hStiaimer: The inspection of this system by St. Croix County does not imply complete
GVliance with State Administrative Codes. There are other areas that it is not possible
,o inepeet at this point of construction. St. Croix County assumes no liability for
j3tem operation. However, if failure is noted the County will make every effort to
itermine cause of failure.
!TEASES A`YD OILS SHOULD NOT BE DISPOSED THROUGH THIS SYS .
• r
qq ''INSPECTOR
DATED cl�� PLUMBER ON JOB m . g
LICENSE NUMBER 3 d S / T-
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sani tan.y PeAmit 3q
State Septic
NAME T,Wv n.6hip St. Crsvtix county
Loca ion SE &6 Section 4Lot Sub divi.6 "
SEPTIC TANK
Size /a�_ gattonb Numbers o6 eomparstment6
Di,6tanee 64om: We,2t 54� '�719 Building o2 �` 1.2% sfope
Highwa-ters
PUMPING CHAMBER
Size gat ones. Pump Manu6dctursers Modet Numbers
HOLDING TANK
Size gateons Numbers o6 Compaktment,6
Pumpers A.tatm Sy,Stem
Di,6tanee �,Aom: Wett Building 12% stope
Highwaters
ABSORPTION SITE
Bed/Ex.3 G Trseneh
Di6tanee {rsom: Wett /00 Buied.Lng M stope
Highwatek
ABSORPTION SITE DIMENSIONS
Width o6 "trseneh l � 5t Req ui. Led arsea �p � � 6t
Length o6 each tine ? 6t Depth o6 nosh below tite in
�� Numbers oo ti-ne�s Depth o6 rsock ovens Cite. in
( /jTotat .length o6 tines 6t Depth o6 .tile betow grsade � �n
Ij� �jD 'A tanee between tines 6t Stope o6 trseneh �i in. pens 100 6t
�� �at abbvrsption akea � .6t Type o6 Covers: Papers rsaw
P1� DIMENSIONS
Numbers o6 pits Grsavet around pits yes no
Outr5ide diametvL 6t Depth betow intet 6-t
Totat ab6orsption area 6x
A,,Le.a rsequ"%rsed bt
INSPECTED BY rl A TITLE. ,111-
APPROVED DATE 198_
REJECTED DATE 198
REASON FOR REJECTION
PLB 67 State and County State Permit #
Permit Application County Perm #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address: ll
WSO n &�*-� 6 10 er
B. LOCATION: '/4 AIE %, Section 93, T,,"&N, R,12 E (or) & Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township rro
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance
Single family _A Duplex No. of Bedrooms No. of Persons__
D. SEPTIC TANK CAPACITY 60 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete_ec_ 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 Replacement e Alternate (Specify)
Seepage Trench: No.of i eaj Ft. Vidth Depth Tile depth (toy)—No.of Trenches
Seepage Bed: A Length Width Depth 919 Tile depth (top)20 No.of Lines 3
Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits
Percent slope of land X912 Distance from critical slope f
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 Certified Soil Testter,NAME The Q S G✓ C�S
e and other information
obtained from r (owner/builder). / p q
Plumber's Signature MP/MPRSW# ,s��! Phone # G' —0��/
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.
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Do Not Write in Space Below FOR COUNTY AND STATE PD
PARTMENT USE ONLY p
Date of Application �° Fees Paid: State_County Date
Permit Issued/R,ejeesed (date) Issuing Agent Name
Inspection Yes4No 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 copy) 4. plumber (canary copy)
Revised Date 7/1/78 �./"�
T
EH 1 1 5 Rev.9/78
• REPORT ON SOIL BORINGS AND PERCOLATION TESTS n
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
'�A�
P.O. BOX 309,MADISON,WISCONSIN 53701
PAO `981 u
LOCATION:51 %a„1 ,E'/a,Section 0 3 T�!N,RAE (or&W Township or Municipality To
Lot No. , Block No. County - Sy' Giro ' J`
tt Subdivision Name
Owner's/Buyers Name: n.�` S D i'1 ^r4l r N'!P k%
Mailing Address:_F.'+C� �jVt:°Y` FQ>1S Wf$. 5'940,2
TYPE OF OCCUPANCY: Residence No.of Bedrooms - COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT—ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE:QSOOIL BORINGS_Apel 1 �-3 �� PERCOLATION TESTS J 3
SOIL MAP SHEET O CO) NAME OF SOIL MAP UNIT A
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P_ I ” b NONE ftfAi I ` s
P-a o o a f,
y " a C 0 0 6 0" re
P- t Alto
P- P e r4 d
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,
TEXTURE,MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B-
B- 5.51 l an S f
B- n 8.1r,1 S I
B—
B—
B—
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan e I catio and uare feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy +a s Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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pp 6
1,the un�rsigend,hereby certify that the soil tests reported on this form were m .1Ilhe in acoo r<�h t e n lures and methods
specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
Name (print) 7A0 Tr 4 dl Certification No.
Address l /S
,Name of installer if known 12S
Copy A—Local Authority CST Signature
x
oc
f=y wag bork, 1 1 {;
REPORT ON INSPECTION OF SANITARY PERMIT # 9�
1 Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection
me, ress, License o. o installing Plumber
Time of Inspection
3 INS ALLATION NSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑Dosing Chamber
❑Seepage Pit ❑ Seepa a Bed ❑ Holding Tank []Fill System
(4)BENCHMARK:k Permanent reference Point) escri e:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well :
(7)DOSING TANK: Manufacturer: # of gallons :
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? []YES ❑NO Wired? []YES ❑NO
8 HOLDING TANK: Manufacturer # of gallons ;
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES [] NO; ft from residence;
ft from well ; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑NO; Wired? ❑YES []NO;
Locking device on cover? [DYES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well ; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth.;
lineal feet tile; ft to residence; ft to well ; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well ; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? [:]YES ❑ NO
(13) Has system been installed in floodway? ❑YES []NO Floodplain? []YES ❑ NO
DILHR-SBD-6095 N.0 /80
Signature of Inspector: