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Form - ST C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Y�i 17 TOWNSHIP 576& „/ SEC. , T JLN-R2W
ADDRESS ST. CROIX COUNTY, WISCONSIN
L
SUBDIVISION ,� LOT ��� LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
i
0 0 On7
se
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a
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used �d
.l 5�
Elevation of vertical reference point: 45i'a a — Proposed slope at site:
SEPTIC TANK: Manufacturer: Lf uid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,Q Rear, O feet
From nearest property line Front 10 Side,O Rear,O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
Alarm Manufacturer:
Inspector:
Dated: � Plumber on j ob: �/ �-s �
License Number: 1 �
3/84:mj
r
�, SANITARY PERMIT APPLICATION
[ °'?' .
(, �iLHR In accord with ILHR 83.05,Wis.Adm. Code " 1 x
STA E SANITARY PERMIT#
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN 1t): UMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NNO
PROPER,V OWNER PROPERTY LOCATION
/a /a, S N, Fi J 7 (Or)
PRO 'S OWNER'S MAILING ADDRESS LOT NUMBER BLOCK UMBER SUB VIS)ON NAME
CIT ,STAT ZIP CODE PHONE NUMBER EJ CITY NEAREST RO D;L E R L DMARK
O VILLAGE
11. TYPE OF BUILDING OR USE SERVED: O L
Number of Bedrooms if 1 or 2 Family �? OR ❑ Public(Specify):
Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ❑ 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. W Conventional 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. X seepage Bed b. ❑seepage 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): '-
Feet Private El joint ❑ PuCi'
VI. TANK CAPACITY Site PR
in allons Total ##of Prefab. Fiber- Ex
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete stru n- Steel glass Plastic App
New Tanks
Se tic Tank or Holding Tank 1,1we Idoo
Lift Pump Tank/Siphon Chamber I I ❑
VII. RESPONSIBILITY STATEMENT
1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's ame(Print): u ber's Sign ure: )o St mps) MP/MPRSW No.: Business Phone Number: s�
en—
P um is Address treet,City tate,Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certifi d S'I Tester(C T)Name CST#
/O
CS 's DDRESS St eet,City, ate,Zip Code) Phone Number:
3 3�
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
,Z1,Approved ❑ Owner Given Initial Su harg�e Fee R p
Adverse Determination � ,)12 �� • �`-'o �
X. COMMENTS/REASONS FOR DISAPPROVAL:
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;
Ill. 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'/ 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 Groundti
included the creation of surcharges (fees) for a number of regulated practices which Wisco in
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re48,11,4411'. e
is used in your building is returned to the groundwater through your soil absorption u
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)
APPLICATION FOR SANITARY PERMIT
STC - 100
his application form is to be completed in full and signdd by the owner(s) of the
roperty being developed. Any inadequacies will only result in delays of the permit
ssuence. Should this development be intended for resale by owner/contractor, ("spec
ouse"), then a second form should be retained and completed when the property is
old and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
er of Property
Location of PropertyE -h; ^�_li, Section W
Township Sd 1Q�
Mailing Address 5 13o I
72cca /2cf/u1,,,,,G J4- s t/or"7
Address of Site
Subdivision Name
Lot Number kq� _
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created / (0— 7 2
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (epee house) ? Yes No
Volume - 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
T We co_A.tL6y that aCC AzRtement's on tl"A ohm ane tAue to the beAt o6 my IouA.)
hncwtedge; that 1 (we) am (ahe) the ownen(a¢ o6 the phopeAty de�schi.bed in thi,a
.in601mation 6o", by viAtue o6 a waAAan.ty deed kecokded in the 06 ice o6 the
Cor►ntyy Re.giAteA o6 Deedi ah Document No. ; and that I (We) pheaentey
nun t1�e phopoaed mite bon .the sewage dispob a a em (oh. I (we) have obtained an
eruemewt, to kum with .the above deg cAibed pnopehty, 6oh. the eonhtnuction o6 acid
system, and the sane ha.s been duty heeohded to the 066tee o6 the County Re9iAteh o6
Verde, ab Voeument No. ) .
SIGNATURE di OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
IJULUhitt,dl 14U. WARRANTY DEED
i' Q(� _ STATE OF WISCONSIN—FORM 1
�� 6 BOOK 4C?fit F°dE44 THIS SPACE RESERVED FOR RtCORDING DATA
THIS INDENTURE, Made this...2.�.th... day of---11 ,ua-ry....... A. D. 19...7.2,
between Mayne--G.A.--Coleman, and...Er ?r...d.....C.Q]..ellalan.,...hia_. Ii r`,l_1-1C
-�!►?,fe..a?�d... a�, ...a.
...th eIr...ma-..ra.ght................................•..........
..............................••-•---................._...._......•--....._..... ._.••-••......._--•---•--•-- ... ............... 26th
.......-............................................-----•---•......-•--•----..part.iss.- of the first part, and
...Richard.-A.-.Mohnsen-mid -..�....�oh his...._.
' d;t) of_J�uzl.lary_ -_I�.U.19_72
...wife...as..aT.oint...Tenant-s....withL.right.s...of..�urvim.ar at_. _2?01q_,__ t'.,
--.WIA.G ms in..................
-
..........
..........._......-......................--..--- ---........_... parte. . of the second part,!,
It• Is �r::-
Witnesseth, That the said art.leS of the first part, for and in consideration
of the sum of_.-...7... ..6ne Dollar and other valuable RETURN TD
._consideration - ._••_•••-•••-..........._..._..._- ..._..._...- - - -•-
-' ' ...................•----------------------......_........
eln.... in hand paid by the said part...I.e.S. of the second part, the receipt
whereof is hereby confessed and acknowledged, ha..Ye.. given, granted, bargained, sold, remised, released, aliened,
conveyed and confirmed, and by these presents do.......... give, grant, bargain, sell, remise, release, alien, convey, and
confirm unto the said part..- of the second part...........their„
.. _............. heirs and assigns forever, the following
described real estate, situated in the County of..-_...Sti.R...S1�Qa,X*............._. and State of Wisconsin, to-wit:
to Town of Stanton
Lot Fifteen (15) of Hook's Second Addition/in Section 31,
Township 31N, Range 17W
it
t
FEE i
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise
appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part-1P'S.- of the
i �
first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and
their 1ereditaments and appurtenances.
To Have an to Hold the said premises as�above�described with the hereditaments and appurtenances, unto I '
the said part•.-_-...... of the second art and to..._........:....................._.._.._.._. hefts and assigns FOREVER.
And the said ..I+wa
3 e... r,.. 91 111 ...aka.. r?r!a_.s�,.... Q .er?na n. ...h , ...W1le......................
.. _-----....•--•- --------•••----•--•---.....•-•----•..........•...............•-•---•-••-.............--•••-•••--
for... themselves, their heirs, executors nd administrators do. .. covenant, grant, bargain, and
agree to and with the said part.A!eS of the second partzheir _ heirs and assigns, that at the time of the
ensealing and delivery of these presents......._.a�?4y_are-_._... well seized of the premises above described, as of a
good, sure, perfect, absolute and indefeasible estate of inheritance in *q law, in fee simple, and that the same are
free and clear from all incumbrances whatever, ...arid no exceplions
..-......-.......... ..................•-----.......----•----••-•---••---•--..._............_.._...
.......--•-•---•-----------------•------...---•--•--------•-•-•--------.._.-•-•--.........---•---_.._...._....................._... - ........ ...._.........
and that the above bargained premises in the quiet and peaceable possession of the said part._ es. of the second
part, -..the.lr......heirs and assigns, against all and every person or persons lawfully claiming the whole or any part
thereof, ------tthlry...... will forever WARRANT AND DEFEND.
In Witness Whereof, the said part.les... of the first part ha..Me.... hereunto set ......their...... hand.$.. and
seal...13. this.......2.61h....._..... day of...........1Tanuar_y........... A 19.72.
SI D AND SEALED PRESENCE OF
............._... SEAL I
_Wa G. Cole n
I �Rh .. _•_ 0,.-Z6,.�� .------- ----- (SEAL)
• y Erma J. Coleman
.0 _..... (SEAL)
I
Cherryj Singerho se
i
i
........................................................................... -...(SEAL)
tate of Wisconsin,
......a� .:_..�'ix'Q1JC••-. County } Personally came before me, this....2.6.t& day of..._..January 9 2,
I the above named .. a .._e... .�_..Co�a rma J. oleman his wife
1 +�. .................s
•--•-•------------••-------------•--•••-••-••--•-----•--. •---•----•-•-----..............--•--........
to me known to be the person.-S wheh
ng ' rum ck ledged the e.
�,.
THIS INSTRUMENT WAS DRAFTED 13Y ".ar A ,`C�.0 O• Wenby
...
Paul 0 n Public .._....tom .Croix..............•--......
Swenby Realt , S County, Wis.
q� A V-so
aussion (expires) .QD.ti.Qb.er....21st. 1.
i►• ' - Off• � -- .7-3-
_—
_ - plainly p, typewritten thereon
(Section 39.31 (1) of the Wisconsin Statute rovbS+that aI1 instrumertts to be recorded shall have laml rioted or
the names of the grantors, grantees, witnesses and notary. Section 39.313 similarly requires that the name of the person who, or govern.
mental agency which, drafted such instrument, shall be printed, typewritten, stamped or written thereon in a legible manner.)
WARRANTY DEED STATE OF WISCONSIN wtsconsln Legal Blank Company
FORM No. 1 Milwaukee, Wis. (Job 29522 )
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STC - 105 r"
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SEPTIC TANK MAINTENANCE AGREEMENT 0
St . Croix County z
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OWNER/BUYER
ROUTE/BOX NUMBER ,
Fire Number
CITY/STATE Z I P-5-4/a/7
PROPERTY LOCATION: 5,E Section T _N , R_/_7 W,
Town of n.,,,15 j St . Croix County ,
Subdivision CMG Lot number
Improper use and 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 , I
if needed , by a licensed septic tank pum er . 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 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 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
H
three year expiration . 0
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I/WE, the undersigned , have read the above requirements and agree C,
to maintain the private sewage disposal system in accordance with H
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 Office within 30 days
of the three year expiration date .
SIGNEDGt
DATE '•tY?wr,,,�/ 9$"8 _
St . Croix County Zoning Office
P. O . Box 98.
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign , date and return to above address .
INDU§TMEIV`f OF REPORT ON SOIL BORINGS AND SAFETY& BlDIVI ION
INDUSTRY, C DIVISION
HUMAN RELATIONS PERCOLATION TESTS,af11J) MADISON WI 53707
(H63.090)&Chapter 145.045)'
LOCATION: SECTION: TOWNSHIP/ ALTY: LOT NO.:BLK.NO.: SUB IVISION NAME:
/ ? / /T N/R/7v(or S
LINTY: o OW S BU ER'S NAME: MA NG ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: A ON TESTS:
Residence ❑New ®Replace Q
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMEN�YSTEM:(optional)
S ❑u 2S ❑� I S ❑� ❑S [Z� ❑S ,Z� ��
If Percolation Tests are NOT requir DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS k l-4
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THIC N SS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH fg, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- ,
B-
R g
B-
B-
r PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IfdettES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 PER PER INCH
P- / - y y
P- l 7
P-
f
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
�
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411- -"1 3t, __ . �_ - "All
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—
1 - _ - -
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I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(prin TESTS WERE COMPLETED ON:
A
CERTIFICATION NUMBER: PHONE NUMBER(optional):
i - , CST SI ATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
P
P �
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test,yoen report mast include:
1. Complete legal description;
2. The use section must clearly indicate whether this"is a residence or commercial project;
3. IVIAX11MUM number of bedrooms or commercial use planned;
4. Is this a new or replacen-lent 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;
0. PLEASE use the abbreviations shown here for vvHting profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating yoarr test locations. Drawing to scaly= is preferred. A
Separate sheet May be, used if desired;
B. klake sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
J. Complete all appropriate boxes as to elates, names,addresses, flood plain data, percolation test exemp-
tion, if appropriate;
?5. 1,the inforrTtat=ein (such as flood plain,elevation)does riot apply, place N.A.in the apprc pt late box;
11. Sign the form and plane your current address and your certification? number;
12. ,Make legihic copies and distribute as rerluired, ALL SOIL TESTS !MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Sail Separates and Textures Other Symbols
10") BR -- Bedrock
co,1) - C;obti'a. (3- 10„) SS — Sandstone
gr — GiavO ,under 3"j LS Linies'tone;
s - Sand HGkN - High Greit.rrtciiiitater
c: t ,�,rs, sand Pe-bc P,rcolatiorn Rate
tired s - Me,diurn Sand Vv _- V ta<
f5 - �nf Sand B dg -. building
1,7 _ Lf ,niy Sand > _._ treater Than
s! Sandy Loam Less Tian
— Loam F'a'n --- Brow^'n
. Loarn fs3 Black
i
C. �l y Yeiiovv
:era 5,�'rc,1°y Clay Lciarn R -- had
Sic! silty Clay Loarn mot itrlottles
ndy Clay ilvi vv!ti
ff, faint
i3ea" iTiIII -_, tvlany, mediurn
"Muck d — distinct
p — prominent
HVVL — High water level,
Six general soil textures surface water
for ligitid kivaste disposal BN1 -- Bench (bark
VRP - Vertical Reference Point
TO THE OWNER:
s
This soil test report is the first step in securing a sanitary permit. The county or the Department may reeluest
cr:ficat;on of this soil test in the field prior to permit issuance A complete set of plans for the private
vvaoe system and a perr” it application must be subrnitted to the appropriate local authority in order to
obtain a permit, -1 hri sanitary permit must be obtained and posted prior to the start of any construction,
1
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•• ������ �o�.�sE� 5���s�/�see �/�,�'l7kJ
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Icrka ,P M Lt, YES p
fv � l Cjlt^+�1�Q^�c� �c1r3 PAGE OF
CrUSS •> �C � IUfI 01" i"1 4JC1� �� Sfc°r►'�
S r
Froth Air Inlalc And Obcsrvation Pipe
Q Approved Vent Cap
Minimum 12"Above
Final Grode
20-42"Above Pipe _4"Coal Iron
To Final Grade Vent Pipe
MOreh Moy Or Synlhellc Covering
Min 2"Aggregate
Over Pipe
Dletrlbutlon
pipe 0 0 0 0 0 —Too
Aggregate
Beneath pipe Pipe Perforated
Betov
o —Coupling
Terminating At
Bottom Of sletent ,
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��tJr.� t I � \N\i I
SOIL FILL
DISTKIBUTIO1.1 PIPE
APPROVED S4NPF_TIC COVER
.• ° "*—MAT1=iii^ OR 9" OF STRAW
2"OF h669 EGATE -�� c OR MARSM HAy
LEV. O COQ l FEET, .e� (e'OF 12 - GGREGATI-
'"8
3 �
3=
DISTRIBUTIOM PIPE TU BE AT LEAST INCHES BELOW ORIGIAIAL GRADE
AkIU AT LEASTZO IAICHES BUT MO MORE THAI) 42 IAICHES BELOW FINAL GRACE
MAXIMUM DEPTH OF F-XC.AVATIOP FKOM OWWAL WK. WILL BE S-1;V INCHES
P 141MUM AEPrh OF EACAVATImN ROM dRI(` 1"AL GRAVE WILL BE 3.7 INCHES
SIGAIED:
LICEMSE AJUMBER:
DATE :
110 1
D.1.L.H.R.
Leroy Jansky, P.S.C.
dustry, INSPECTION 13 E. Spruce Street
Wisconsin Departmen ions
Labor and Human ivision REPORT Chippewa Falls, WI 54729
Safety&tiujl�ing (7 15) 723-8786
Bureau ornate
Name of Pre ises Address or Legal Description �ily/Township County
c.. !X.
Master Plumber Name and Address Master Plumber Firm Name and Address Plan I.D.No.
Sanitary Permit No.
n /
Journeyman Plumber/Soil Tester Licensed Person's Name(s)and License Number(s)
Owner's Name and Address
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Page 1 of Signature of Responsible Licensed Person(bqly one needed)
Signature of Plumbing Consult nUP,rivaI-z6% s Consultant
(Check all }
Original: Copies to: that apply 4
SBO-6192(R.11/85) District 0DILHR (,,�Piumber Owner C4u4jLocallnsp. Other
Wisconsin Department of Health and Social Services
Plb. 467 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY,.,
Check Ones
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHti
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO �/ PERMIT NUMBER
D, SEPTIC TANK CAPACITY -''4 Gallons NEW INSTALLATION 4- REPLACEMENT ADDITION
t -
MATERIALSt Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS ?0 BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: one or Two Family Residence � Commercial Industrial Other
Specify
Number of Persons to be Accommodated S Number of Bedrooms S
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES
Dishwasher YES � NO
N NO
O Automatie Potato Peeler YES
Other (Specify)
G. MASTER PLUMBER MAKING NS
7ALLAT ON
J
Name: 1' Address: i J/ 7� License Number:
HP ve ��5—�
Signature of Applicant M P RSWA 62-3
Address: �Z`,J G� ';�L •✓.-.�---
H. (?o e 7pieted by Issuing Agent)
Date of Application - 0 Fee Pold t
Permit Issued (date"--- e3, 7 el Permit Number
Agent (Name) 2- �'C� ��' For ��. .tli
Town Vllllage, City, County, Ste.
(Specify)
Notes The application cannot to :onsidered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.OG for each s+a-ptic tank and the third copy
of the permit (canary' to the Division of Health. Checks and money ordnrs should be made peyable to
the Division of Health.
Do not write in space below FOR DEPARTMENT USE ONLY
I. DATE RECEIVED 7 ACCEPTED BY }'' RETURNED
(Initials) � `/�� (Date) See Corres.
FEE RECEIVE VALID. No. / PERMIT N0.
es or NOTE
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE CYPHER SIDE
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16
SEPTIC TANK PERMIT N0,
R Z P O R T O N S O I L P S R C O L A T I O N T E S T
A N D S 0 I L B O R I N G S
TO
DIVISION OF HEALTH - PLLMBING SICT16M -
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
PERCOLATION TEST
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches Minutes
Number Inches Thickness in Inches Sineo Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnikht in Minutes Last Period Last Period Period Onef Inch
Example
p - 0 36" Top Soil low, Cla 26" 25 Yes or No 30 1A 1 2 1 60
'1 �5F J
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S - Minimum 36" Below Prc osed Abso ion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed I Estimated Character of Soil with Thickness in Inches
Example
B - 0 72" 72" Black Top Soil 12"t Clay 18"j, Sand 18:1 Gravel 24"
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
PE OF OCCUPANCY:
RESIDENCEs Number of Bedrooms _ OTHERS (Specify) Number of Persons
WASTE GRINDER: Yes No _Dishwashert Yes No Automatic Clothes Washers Yes 1 --No
FFWENT DISPOSAL SYSTEM: NEW 7XTENSION ADDITION -..�.r REPLACEMENT
Tile Size No.Lin.Feet !� Trench Width Depth Number of Lines
Seepage Bed: Length-70 Width -,' Depth ! Tile Size No. Lines •:_..�
Seepage Pits Inside Dlameter� Liquid Depth
I, the undersigned, hereby certify that the peroolation.tests reported on this fora were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data re ofded' d location of test holes are correct to the best of my knowledge and belief.
NAME / r� . f�-[ TITLE .
Type or Print)
REGISTRATION NO. !' 'f Or MASTER PLUMBER LICENSE NO.
ADDRESS -
DATE '- r J SIGNATURE 4L
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