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HomeMy WebLinkAbout030-2036-30-000 2 0 2 $ 2 � R & o e ■ c W 0 ] � � ) � § � A � � § : � a § ) Z 2 ` E / $ 2 2 � ■ � � / w E m : " 0 z / C) 12 C-4 p $ a ■ g � ) 2 « 2 \ } k 7 / / 2 I � @ � � O 2 } ) -� CO k } Q kcaz / .. ) Cl) � 2 C 2 � § .5 ^ ■ . � o f g % c § I o ; � o o a I « \ o _ \ \ k } - t \ a a a « I j � § 0 k k ° � 2 ( 5 © 12 S ® 2 § C G \ / Ec I � \ fU a$ 7 = m 2 2 / < \ � \ 2 # E _ r r S k k k 8 2 t 8 8 5 2 S o n o 4) ' t / _ - I a \ z z k g o a , 8 • a « , Cl) 't / ; 2 2 0 § § 2 § o 04 m o z 2 e w s m % k a , ■ � k � IL w 2 E � ) a § & 0 0 U) 2 , _ Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER c5CO `Z: C N g Qe/ dNSHIP 3 �OS��A _ SEC. T _N-R�W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT 0M,4 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IILHR 83 ' SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM C' wet'- &us 9 i _ 4 rd f � a A L. Q� INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ,j E, C.O T S rA Elevation of vertical reference point: /Qd„ Proposed slope at site: S1116 I SEPTIC TANK: Manufacturer: WASj6.AL- s Liquid Capacity: W106 Number of rings used: �_ Tank manhole cover elevation: LQ Y,Q Tank Inlet Elevation: Tank Outlet Elevation: 101,34 Number of feet from nearest Road: Front, Side, Rear, O feet From nearest property line Front 10Side,WRear,0 ISO feet Number of feet from: well �, building: 2j? ' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE _J PUMP CHAMBER nufacturer: Liquid Capacity: Pump Mo Pump/Siphon Manufacturer: Pump Size Elevation of inle Bottom tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm SwitcEType: Number of feet from arest property line: t, ide, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: �j Length: 7S Number of Lines: Area Built:— 250 Fill depth to top of pipe: 3C " Number of feet from nearest property line: Front, O Side, Rear,O Ft .-ILY Number of feet from well: Number of feet from building: 71 (Include distances on plot plan). PAGE PIT Si Number of pits: Diameter: Liquid de h: Bottom of seepage pit elevation: Area Built: Has either a drop box r distribution box O been used any of the above soil absorbtion sytems? (Check one HOLDING TANK Manufacturer: Capacity: Number of rings used: levation f bottom of tank: Elevation of inlet: Number of feet fro earest property line: Fro O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: �y Inspector: Dated: `��T_ Plumber on job: License Number: 3/84:mj DEPART.MEAIT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&HUMAN RELATIONS DIVISION P.O.BO,X 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: SE 4i SE 4,S24,T3iN-R20W CONVENTIONAL ❑ ALTERATIVE (if assigned) Town of St. Joseph ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound E D R: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Scott Schroe fer 1740 Marion Street. Apt. #13 Roseville MN Y Jc5 3 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: Donavin L. Schmitt 3205 St. Croix 112843-T SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY TA/NK INLET ELEV./ TANK OUTLET ELEV: WARNING LABEL LOCKING COVER P Q YES ❑NO PROVIDED:❑YES &NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM / L7y �� AIR�LL.6�_ ❑YES NO C ❑YES ❑NO NEAREST—► / DOSING HAMBER: MANUFACTURER: I BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑YES ❑NO NEAREST--01- 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 DIMENSIONS � ,5 NO OF : C r 7 M7, P_ PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRES}i BELO PIVS: A COVER: ELEV.INLET: ELEV.END: r� q PI FEET FROM LINE: AIRJE G )C9 n C �U�. Z C J 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 j TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED I 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: 5AREST'MBER OF PROPERTY WELL: BUILDING: COMMENTS: ET FROM LINE: 3 5 ❑YES ❑NO [--]YES ❑NO ♦ Sketch System on ain in county file for audit. Reverse Side. SIGN TITLE: SBD-6710(R.06/88) SANITARY PERMIT CR&x COUNTY ®ILHO TRANSFER/RENEWAL UNIII i M 1 # sW a� (PLB 67-T) PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL SSUA NC�jE DATE: STATE PLAN I.D. NUMBER: 5l, PROPERTY LOCATION: CITY: VILL '/o '/4,S ,T 30 N,R 0 E (or W N OF Q LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUM 'S SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGED): PL BER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS: 7EN �MP PRSW NUMBER: PHOUMBER: M RSW NUM PHONE NUMBER: Zs-1 ( i�► G-G o SI NA RE PPRO VED: DISTRIBUTION: Original-County Copy-Bureau County Plumbing Copy-Owner Copy-Plumber nii ua_cRn_F3g9 IR_ 5/R21 h SANITARY PERMIT APPLICATION COUNTY I-A R� In accord with ILHR 83.05,Wis. Adm. Code St .Croix a STATE SANITARY PERMIT# fete plans(to the county copy only)for the system,on paper not less than es In size. STATE PLAN I.D.NUMBER - e side for instructions for completing this application. PETITION ANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE El YES X NO OWNER PROPERTY LOCATION Schroe fer SE '/4 SE '/4, S 24 T 30, N, R 20 >f:(or)W �ppPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME 1740 Marion St. Apt . #13 n/a n/a n/a CITY,STATE ZIP CODE PliON NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK Roseville, Minn 55113 E�l� 87-185 E3 VILLAGE: St . Joseph Co. Rd. 47V 11. TYPE OF BUILDING OR USE SERVED: 5130' .-AGL3 - Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. P New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Sdptic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued 3. ❑ An Existing System has been inspected and soil donditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. Oconventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e.❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ See age Bed b. EkSee a e Trench c. ❑ seepage Pit 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): class 2 710 750 103.05 Feet Private ❑Joint ❑ Public VI. TANK CAPACITY in alions Total #of Site INFORMATION Manufacturer's Name Prefab. Con- Stee Fiber- p . New xistin Gallons Tanks l plastic A Concrete glass App. Tanks Tanks structed 3e tic Tank or Holding Tank x _1000 Weeks r P_ -ift Pump Tank/Siphon Chamber --------- I LLJ_1 El F_H_ Al. RESPONSIBILITY STATEMENT IEEHIFTR� I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. 'lumber's Name(Print): Plum 's Signature: No S m ) PRSW No.: Business Phone Number: Gar L. Steel > 3254 715 246-6200 Slumber's Address(Street,City,State,Zi de P ) Name of Designer: 988 N. Shore Dr. New Richmond Wi . 54017 JII1. SOIL TEST INFORMATION :ertified Soil Tester(CST)Name CST# Gary L. Steel 2298 ,6 I's ADDRESS(Street,City,State,Zip Code) Phone Number: 988 N. Shore Dr. , New Richmond, Wi . 54017 715 246-6200 X. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Iss ing Agent Signature(No Stamps) Approved ❑ Owner Given Initial r� rc ar a Fee 1 Adverse Determination /6^a 7^ C C MENTS/REASONS FOR DISAPPROVAL: 3D-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber of K�,,e County gilst o )Deeds, as Document No.L L't- / Signature of ne Signature of Co-Owner (If Applicable) taee of Signature Date of Signature T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS JDUSDUSTRY, DIVISION UMO�J' RELATIONS PERCOLATION TESTS (115) P.O. BOX 3709 ppoo 1 / MADISON,WI 53707 (H63.09(1)& Chapter 145.045) OCATION": SECTION: TOWNSHIP/�: LOT NO.:BLK.NO.: SUBDIVISION NAME: SE �/ �/4 24 /T30 N/R2 or)w St Jose h n/a n/a n/a OUNTY: R'S BUYER'S NAME: MAILING ADDRESS: ;t-- Croix --Scatt Schroppfpr 11740 t A 13 Roseville, Minn. 55113 SE DATES 013SERVATIONS MADE NO.BEDRMS.]COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence �lew ❑Replace 3 n/a _ 5-9-88 n/a ATING:S=Site suitable for system U=Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYST M-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) li Q S ❑U QS El U us 11 U I [Is QU Os &A conventional Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the nder s.H63.09(5)(b),indicate: class 2 ( n/a Floodplain,indicate Floodplain elevation: • , PROFILE DESCRIPTIONS a e 33 OMC2 ORING TOTAL P H WED UNDWATER-INCHES CHARACTER OF SO L WITH THICKNESS COLOR TEXTURE AND DEPTH UMBER DEPTHNK ELEVATION OBSERVED ES GH TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) ;- 1 6.92 106.51 none >6.92 .83bl.1. 1.17bn.sil. 4.92bn.1s.&gr. 2 6.92 106.59 none >6.92 .58bl.1. .,67bn.sil. 5.67bn.l.s.&gr. 3 7.17 106.05 none >7.17 .92bl.1. 1.33bn.sil. 4.92bn.l.s.&gr. 3. 4 6.67 104.37 none >6.67 .67bl.1. 1.00bn.sil. 5.00bn.l.s.&gr. 3- 5 6.76 104.05 none *6.76 .67bl.1. 1.17bn.sil. 4.92bn.l.s.&gr. 3- PERCOLATION TESTS TF-ST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES JUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERIOD2 PER INCH se de rate P- .OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ntal 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 land slope. YSTEM ELEVATION 103.05 �kti, 3� TH ( 5*5 4 6 17 EN 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 dministrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. AME(print): TESTS WERE COMPLETED ON: Gary L. Steel 5-9-88 DDRESS. CERTIFICATION NUMBER: PHONE NUMBER(optional): 988 hmond. Wi. 54017 r CST SIGNA 7 / c. ISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. ILHR-SBD-6395 (R.02/82) —OVER -- a SE4SE , S24T30N. R20W St . Joseph, twonship .. [Y Z 3 w 8 3 ---- — { B � /,S'Z Cm = 5 E, W C,rv^ f�+� e`Sra ire- *A r4 rz� 63,10 r - , Scott 3cnreopher SE4SEti S24T30N. R20W St . Joseph, twonship 7� a - � CjvA� fit, .-t-,4 0— B 3,10 \ Gary L. Steel 988 N. Shore Dr. New Richmond, Wi . 54017 MPRSW 3254 DEPARTME f OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LABOR& UMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION R.O. BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 SE�-4,SE,14,S24,T3ON-R20W UCONVENTIONAL ❑ALTERNATIVE Sllaass"anI,D,Number- Town of St. Joseph El Holding Tank ❑ In-Ground Pressure ❑Mound Countur Road V NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER INSPECTION DATE Scott Schnoeyjk n 1740 MaAion StA. Apt. #13, Roz evi% e, M 55113 BENCH MARK(Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.. CST REF.PT.ELEV. Name of Plumber: MP IMPRSW No.: County Sanitary Permit Number: CyoAU L S e� 3254 S Ctcoix 112843 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED E:]YES FIND I ❑YES ONO BEDDING VENT DIA, VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: (VENT TO FRESH ALARM LINE. AIR INLET FEET FROM DYES ONO DYES NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. 111OU111CAPAC11Y PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES ❑NO DYES ONO I DYES ONO GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING V NTTO RE H (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 LENGTH DL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO.OF DISTR PIPE SPACING COVER INSIDE DIA -PITS LIQUID BED/TRENCH TRF.NCHES 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 EI FV INLF f ELEV END PIPES FEET FROM LINE AIR INLET: _l NEAREST--► 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 TEXTURE PERMANENT MARKERS JOBSIFIVATION WELLS ❑YES 1:1 NO 1:1 YES ONO DEPTH OVER THE NCH BED EPT"OVER TRENCH.HEU DEPTH OFTOPSOIL SODDED [11111D MULCHED CENTER EDGES 1:1 YES ONO 1:1 YES 0 N I1-1 YES NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLDMATERIAL. NO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV. EIFV. DIA. ELEV.. PIPES DIA DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLEDCOHRECTLY COVER MATERIAL VERTICAL LIE T CORRESPONDS TO APPROVED PLANS 1:1 YES 0 N ❑YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING. FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST it I Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE Zang Admivw,tr, DILHR SBD 6710 (R.01/82) ato, =Zairl SANITARY PERMIT APPLICATION COUNTY EHR In accord with ILHR 83.05,Wis.Adm.Code St.Croix STATE SANITARY PERMIT# � 8 �3 —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. FFOR ON 1. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION. RIANCE ❑YES N NO PROPERTY OWNER PROPERTY LOCATION Schroe fer SE '/4 SE '/4, S 24 T 30, N, R 20 E(or)W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 1740 Marion St . Apt . #13 n/a n/a n/a CITY,STATE ZIP CODE P ONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK Roseville, Minn 55113 P612 87-185 ❑ VILLAGE: St . Joseph Co . Rd. ##V II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. PK9 New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. Oconventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d.❑ Vault Privy e.❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. 6Ekseepage Trench c. ❑See a e Pit 2. PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): class 2 710 750 103 .05 Feet SPrivate ❑Joint ❑ Public VI. TANK CAPACITY Site in ga ons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank X Li Pump Tank/Siphon Chamber --- -----1000 ELI] 1 ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plum s Signature: No S m ) PRSW No.: Business Phone Number: Gary L. Steel 3254 715 246-6200 Plumber's Address(Street,City,State,Zip de): Name of Designer: 988 N. Shore Dr. , New Richmond, Wi . 54017 Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# Gary L. Steel 2298 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: 988 N. Shore Dr. , New Richmond, Wi . 54017 715 246-6200 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved SanitarytPlJernmit Fee Groundwater @7e Iss ing Agent Signature(No Stamps) rz?r lrV rc ar e Fr�� /Q�a 7—& f+� Approved ❑ Owner Given Initial `.V Adverse Determination X. C MENTS/REASONS FOR DISAPPROVAL: r„ SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system..Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/z 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground Ater T included the creation of surcharges (fees) for a number of regulated practices which Wisco ID'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r re is used in your building is returned to the groundwater through your soil absorption e system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- . t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) f 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 l r d ejt2 It t-L'' Location of property cSL 1/4 -SC� 1/4, Section � �" , To3e) N-R_ d W Township �7 4�1 S GL�2 Mailing address yr/! Address of site �� • ��� Subdivision name Lot number / " 1 ,4 Previous owner of property 74_�' ' r1�5 J6 Total size of parcel X71 /9lL2 S Date parcel was created S . P� Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes L----No Volume 9---21 and Page Number ----7 S 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. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ,S/�o� S ; 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 f` of t e County gist o '/Deeds, as Document No. ) . i Signature of Q"ei Signature of Co-Owner (If Applicable) Date of Signature Date of Signature T. STATE•AR OF W000119I1 t011M 1�1� 7+1Mr gtlM I f N WARRAWY ono �,,,�, „ ' 440535 71'19 621 o�.E 25 Anita Pringle, a single person T. s eanwysandwamnts to Scott A. Schroe fer and Jenni er L. at 1:45 Schroepfer, as survivorship marital property Q �Reguter ei OssM , RETURN TO tea following described real estate in St. Croix County. Stalsof Who -in: Part of the SE 1/4 of the SE 1/4 of Section 24, Township TaxPwvmHS: North. Range 20 West, Town of St. Joseph. St. Croix County, Wisconsin. described as follows: Lot I. Certified Survey Map. A recorded August 18. 1988, in Vol. 7. page 2013. as Doc No. 440609. t-• TRAI VER j FEE }: I This is not homestead property. Us) (is not) Exception to Warranties: r +,is r Doled this 19 ___-- —dayof August_ (SEAL) — `— AEAI) CATHY SEXELL Anita Pringle • ` �..111dBE � Call 0 MMSET COUfITT yjpiret 3.11.93 ... (SEAL) AEA ) 4! AUTHENTICATION ACKNOWLMOMENT a',ignatureM) STATEOFVN300N= M i nne e t a —_ kamsFV �p• auMtsntieslsd this day of 19 Personally came before me this 19 day of ,19_ R the above named --- - - '- :1.71L:1 i'rinylt•, a xinvl. nerc,,n TITLE:MEMBER STATE BAR OF WISCONSIN of not• to me known to be the person who onsopNd the aull""Zed by 1708.06.Wis.State.) foregoing instrument and aoknowiedge the am*. TH1S 1NSTRUMENT WAS DRAFTED ev , —First Security litle 2785 White Bear Avr• Mapl'.Wo ,d M'N i i Illy _ Cati,v Bux I 1 ` Notary Public County,Wis. (Signatures may be authenticated or acknowiedged. Both My Commission is permanent. (it not, slate SnWs en we not necessary.) , date 1 11 19 q i _.) '"was$SOW4 MNtMe In SOY txlI v otould se typed or printed tt•be1 their eteneiwee pTR MAMAe1Tq OEEO fTATt EAR Of WIeCONNN NoWn Formf A O aei.102gf Green Gay? solw-em Pant No 2 r STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT. St. Croix County OWNER/BUYER '.L:'�!�� r� ROUTE/BOX N ER� �'/—A7 � � 1 FIRE N0. CITY/STATE � , �,�<� ZIP PROPERTY LOCATION: 1/4 °5& 1//4, Section Z `'L , T 3 49 N, R ZO W, Town of -*/- -5 �J , St. Croix County, Subdivision ��9 , 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.Cr ix County ing Offic within 30 days of the three year expiration date. i SIGNED 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 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, .� DIVISION LAVdRWD PERCOLATION TESTS (115) MADISON WI 53707 HL1MAN RELATIONS (H63.09(1)& Chapter 145.045) LOCATION: SECTION: TOWNSHIP/�: LOT NO.:BLK.NO.: SUBDIVISION NAME: E 1/ E 24 /T 30 N/R20LA or)W St. Jose I n a I _n La n a COUNTY: R'S BUYER'S NAME: MAILI G ADDRESS: St-._ C-roix Scott Schroppfer 1740 Marion St. Apt. 13 Roseville Minn. 55113 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILED S RIPTIONS: R A ION TESTS: ®Residence 3 n/a �lew ❑Replace 5_9_88 n/a RATING:S=Site suitable for system U=Site unsuitable for system CONNVnVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) u S ❑U Q S ❑U ®S ❑U ❑S A ❑S conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: class 2 Floodplain,indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS -page 33 OMC2 BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTHXK OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.( B- 1 6.92 106.51 none >6.92 .83bl.1. 1.17bn.sil. 4.92bn.1s.&gr. B_ 2 6.92 106.59 none >6.92 .58bl.1. .67bn.sil. 5.67bn.l.s.&gr. B_ 3 7.17 106.05 none >7.17 .92bl.1. 1.33bn.sil. 4.92bn.-l.s.&gr. B_ 4 6.67 104.37 none >6.67 .67bl.1. 1.00bn.sil. 5.00bn.l.s.&gr. B_ 5 6.76 104.05 none *6.76 .67bl.1. 1.17bn.sil. 4.92bn.l.s.&gr. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER INCH P- P- P- see desim rate 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 103.05 l h _ _ w timm � K LOd� — w 1 ! ( f I k _ tN -- ° 1 r 4 � k ._-].._ _ _. _ ,_,,. ___..-__ i ...,, �---.._._.....�.,. .,i..i ti t� 3 - _ T t - k I L k 7 1,__J_ _L 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: Gary L. Steel 5-9-88 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 988 N. shore DR. . New Richmond, Wi. 54017 229 1 / 1715-246- 200 CST SIGNA DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — r �J4 INSTRUCTIONS FOR COMPLETING FORM 115- SRI - 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 Manned; 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 RASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shown here for v✓riting profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be, used it desired; S, Make sure your benchmark and vertical elevation reference point are clearly shown,and are per 9. Complete all appropriate boxes as to dates, names,addresses, Mood plain data, percolation test exemp- tion, if appro[a late; 10. If the information (such as flood Plain,elevation) does not apply, place N.A. in the appropriate box; 11. Sigrr the form arxi place your curre.rit address and your certification number; 12. Make legible copies and distrihote, as rectuired. ALL SOIL TESTS MUST BE FILED VVITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIES SOIL TESTERS Soil Separates and Textures Other Symbols st - St.om (over 10") BR - Bedrock cols - Cobble (3- 10") SS Sandstone gr, - Gravel (under 3") LS Limestone �s - Sand H VV - High Gror,nndwater cs Coarse Sand Perc, Percolation Rates med s - Medium Sand W - Well `s Fine Sand Bldg -- Building Is - Loarny Sand > - Greater Than 'sl Sandy Lo am < -- Less Than "I -- Loam 13 _.- Brown `sii Silt. L.o.ar?t B1 _ Block si - Silt C1y - Gray �cl - Clay Loam Y Yellow scl - Satiny Clay Loarn R - Red sicl - Silty Clay Loam mot Mottles sc Sandy Clay w - kvith sic - Silty Clay fff fine,(taint - Clay cc - common, coause pt - Peat mrn - Many, rnedium err -- Muck d distinct: p - prominent: €- IV' L - High water level, Six general soil textures surface water for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Pont TO THE OWNER: This soil test report is the first step Ire securing a sanitary permit, The county or the Department may request verification of this so l test ill the fiold prior to permit issuance_ A complete set of plans for the private slvvage system and a pemiii application mr.ast he su,rnaitted to the <aPpropriate local authority in order to obl-ll a permit. she sanitary Permit must he obtained .and posred prim to 'he start of ar= r,,o�is ucttori. Scott Schreopher SE4SE4 S24T30N. R20W St . Joseph, twonship 7 Q .$ G � ,v IL Bi �m = s.E, 7`S II Gary L. Steel 988 N. Shore Dr . New Richmond, Wi . 54017 MPRSW 3254