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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Ne-,1 e— �i^ao%nA�i s TOWNSHIP �7/uuJ�� SEC. T �7 N-R ��o W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION /114 LOT AX LOT SIZE A/x
PLAN VIEW
Distances and dimensions to meet requirements of IIHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
�Inus� 16100
to � F
xI
&21
e�
Sys
0
N Q,M,
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 3,fer- qr 7• /'$7 o Of
Elevation of vertical reference point: /o0-6� Proposed slope at site: Z /0
SEPTIC TANK: Manufacturer: �Ee_' $ Liquid Capacity: /000 cpa L
i
Number of rings used: Tank manhole cover elevation: AV,O z
Tank Inlet Elevation: Tank Outlet Elevation: 9A'.38
Number of feet from nearest Road: Front,�Side,�Rear, /�� feet
From nearest property line : Front,0 Side,0Rear,O ';;'�0 + feet
Number of feet from: well S/' building: 20�
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
a
PUMP CHAMBER
Manufacturer: /P_C'_°ri S Liquid Capacity: 1?A-,
Pump Model: L Pump/Siphon Manufacturer:, (Y-04w/g// Pump Size
Elevation of inlet: ,21009 Bottom of tank elevation: >
Pump off switch elevation: 4 9 Gallons per cycle: /l0 9•�
Alarm Manufacturer: Xlap�177 -1'aJ\ Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, Rear, Ft.30�f
Number of .feet from well: �� /
Number of feet from building:_z
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: YS Trench: �-
i
Width: Length: 17 Number of Lines: Area Built: 3741,
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, ® Rear, Ft .300
Number of feet from well: /,G�0
Number of feet from building: 'IV/ 7
(Include distances on plot plan).
SEEPAGE PIT
Size: Numbed{ o pits: �" AD et
Liquid depth: / Bo tom of ;seepage pation:
Area Built:
Has either a drop box O r distrifbuti n box O en use on any of the above soil
absorbtion sytems? (Chec one) .
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Ele' ion of botto� of to
Elevation of inlet: �
Number of feet from nearest prop ty 1 ne: Front, Side,"O Rear,
0 Ft.
Number of fee from w 11: �
Number of feet om building:
Number of feet from earest road\._ Ll
Alarm Manufacturer:
Inspector:
p r
Dated: �i 7 0 /r� Plumber on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS
LABOA&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX A969' BUREAU OF PLUMBING
MADISON,WI 53707
NEk,SEk,S6,T29N—R16W ,CONVENTIONAL E]ALTERNATIVE State Plan I.D.Number
Town of Baldwin ❑Holding Tank ❑ (l signed)
In-Ground Pressure ❑Mound _
220th Street t
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSP C ON DATE
Neil TeGrotenhuis Route 1 , Baldwin, WI 54002 tc,-IS'_$7
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:
Dale E. Hudson I6629 St. Croix 95976
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCK G COVER
Q P O IDED: P .
17- a YES ❑NO YES ❑NO
BEDDING: VENT DIA.: VENT MATL.. HIGH WATER N�MBR. ,ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM. FEET FROM LIN S AIR INLET.
DYES NO ❑YES ONO INEARF-s*r', ( c! Vd `�V
DOSING AMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY 111111111111. PUMP/SIPHON MANUFA TU WARNING LABEL LOCKING COVER
8 � PEiOVIQED: PROVIDED:
�fl/✓✓ ❑YES NO (� YES ❑NO DYES KNO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL PtI.M'SIER OF PROPERTY WELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LI / AIR IN�LJET:
PUMP ON AND OFF) DYES ❑NO NEAREST—_-•�► 4
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 IFOR / Z
the soil is dry enough to continue.) (p J
CONVENTIONAL SYSTEM:
■■��,� '-WIDTH: LENGTH NO.OF DISTR.PIPE SPACING: COVER JINSIDE DIA.. #PITS. ILIOUID
"EfJ:�x TRENCHES: MATERIAL: PIT'! DEPTH:
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR "€ fJF PROPER TV WELL: BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER. ELEV.INLET.ELEV.END. PIPES. J'UM FR,O LINE: AIR INLET:
_ N.EAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
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 XTURE 1PERMANENT.c�// MARKERS: OBSERVATION WELLS
L�GYES 1:1 NO YES NO
DEPTH OVER TRENCH/BEID EPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED. SEEDED. MULCHED.
CENTER: / JED.ES ! _ /' 1 ,-{�
V 1:1 YES O N0 VYES ONO kYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
aSa �_ II# � WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE.: FILL DEPTH ABOVE COVER
TRENCHES:
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
E LE V.. ELEV. DIA. ELEV.: PIPES: DIA.:
!� HOLE SIZE- HOLE SPACING: DRILLED CORRECTLY. COVER MA ERIAL: VERTICAL LIFT CORRESPONDS TO APPRGVED
PLANS.
YES
E NO -]YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: �OF " .'PROPERTY WELL: BUILDING:
° �ES 1-1 NO o�
NYE ES ❑NO 7
�1FES�
Sketch System on Ret in county file for audit.
Reverse Side.
SIGNATURE: TITLE:
DILHR SBD 6710(R.01/82)
Zoning Administrator
T
i
—�- SANITARY PERMIT APPLICATION COUNTY
� DILHFi In accord with ILHR 83.05,Wis.Adm.Code
STATE SANITARY PERMIT#
–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. PETITION
1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO
PROPERTY OWNEERR� PROPERTY LOCATION
A
✓c� '� /r° /'o� �L/i - %S %, S 1p T,2 , N, R 4 (or)
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY,STATE ZIP CODE PHONE NUMBER CITY Q �i� NEAREST ROAD, KEG LANDMARK
/�� ) VILLAGE : J
11. TYPE OF BUILDING OR USE SERVED: 120A /M• 0J.4 – C(,)`_60-0700
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): SIX
III. 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. ❑Conventional b.,K Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.X Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a-,&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): a
.,3'�� 9/�106 Feet CZPrivate ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete structed glass App.
Tanks 1 Tanks
Septic Tank or Holding Tank /QQO
Lift Pump Tank/Siphon Chamber 9001 ❑ ❑ 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
- e sow -77
/3
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
tia Approved wrier Given Initial charge Fee� �r •� `7/7�}
Adverse Determination L� ^ U i3J ,,j
X. COMMf ENTS/RE DONS FOR DISAPPROVAL: �� j� i `
I Qh 1��? 6�S C z C "
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
s
a
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 applica+:ion must include:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
11. 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;
111. 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'/2 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
commoniv known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public deaate. The groundwater bili Ground ate,r—
included the creation of surcharges (tees) for a number of regulated practices which Wiscor4in'S °
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water,that buried freasure
s used in your building is returned t,- the groundwater through your soil absorption o ,
system or the disposal site used by your holding tank pumper.
a
The ; ionies collected through these surcharges are credited to the groundwater fund adminis- °
t e•.. by lie Department of Natural Resources. These funds are used for monitoring g-ound- f
grc,undwaier contcmination investigations and establishment of standards. Groundwater,
at.('nr; protecting,
APPLICATION FOR SANITARY PERMIT
S T C - 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"1, 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 � . ✓� ��,�o/e✓I /1/�, /�
Location of Property _ SE 14, Section 6 , T Z q N - R Ae, W
Township _ 30/d GtJ/,/9
Hailing Address �J, �u
Subdivision Name
Lot Number
Previous Owner of Property CL)neLo //e C'.c�ofe��i�ris � �11�/ /�s�/✓7�i-e�!f
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yea No
Is this property being developed for resale (spec house) ? Yes X No
Volume 2v ! and Page Number /Zz as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
WarrantyDeed
2. Land Contract
3. • Other recordings filed with the Register of Deeds Office
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
Hap, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) eentt6y that a t 6tatements on thiA 60nm cute true to the but o6 my (oun)
knowledge; that I (we) am (ane) the owner(6) o6 the pnopen.ty de.a cA bed in th,iA
in6orcmati,on 6onm, by vL ttue o6 a warranty deed neeonded in the 066.tce 06 the
,County Reg•i.aten 06 Deeda ab Document No. Z53?AIZ ; and that I (we)
pneaentty own the ptopoaed d.cte bon. the sewage dizpozat aystem (on I (we) have
obtained an eUement, to nun With the above dezcAi.bed pnopenty, bon the
conataucti.on o6 .6ai.d system, and the dame has been duty neeonded in the 066.bee
o6 the County Reg,ieten 06 Deeda, as Document No. ) ,
SIGNATURE OF OWNER SIGNATURE OF- CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
(� .1 4 c .
` No.4.1. Warranty Deed—Common Dorm VWTATfiV (W�kONB
Sm 235.16, Wig. Statuteg. Form No.I published by Eau Clnlre Book S Shtionery Co,
Lbit, •niMilu P.Made this 1 ' day of March A. D., 19 gg ,
between
Cornelia Te Grootenhuis, a woman and Wilma Van Someren, a woman, each
in their own right
part ies of the first part,and
Cornelius Te Grootenhuis and Alice TeGrootenlauis, husband and wife
and as joint tenants
part ies of the second part.
CaftnrOotth: That the said part ies of the first part, for and in consideration of the sum of
Twelve Thousand and no/100 ($12,000.00) ----------*-------------
-dollars
to them in hand paid by the said part ies of the second part, the receipt whereof is hereby
confessed and acknowledged, ha vegiven,granted, bargained, sold, remised, released, aliened, conveyed
and confirmed, and by these presents do - give, grant, bargain, sell, remise, release, alien, convey and �I
confirm unto the said part iesof the second part, their heirs and assigns
forever, the following described real estate,situated in the County of St. Croix
and State of Wisconsin, to-wit: e
i
Southeast Quarter of Northeast Quarter (SEJ of NE-4'-) and Northeast Quarter
of Southeast Quarter (NE-,f of SE-41) of Section 6, Township 29 North, Range
16 West, St. Croix County, Wisconsin.
111IIIIH , •� 1 1111.1;{ I
1
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31
1,
I
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II Z ugcoeC with all and singular the hereditaments and appurtenances thereunto belonging or in anywise
appertaining; and all the estate, right, title, interest, claim, or demand whatsoever, of the said part ies it
of the first part,either in law or equity,ether in possession or e.tpectancy of,in and to the above bargained
premises and their hereditaments and appurtenances.
L.0 1t1UC d1lb t0 t?olb, the said premises as above described with the hereditaments and appurtenances,
unto the said part ies of the second part, and to their heirs and assigns FOREVER.
kIn0 the 'Aaib Cornelia Te Grootenhuis and Wilma Van Someren
for their heirs, executors and administrators, do covenant, grant, bargain and
agree to and with the said part ies of the second part, their heirs and assigns, that at the time of
the ensealing and delivery of these presents they are well seized of the premises above described,
as 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 incumbranbes whatever, No exceptions
and that the above bargained premises in the quiet and peaceable possession of the said part ies of the
w
second part, theirheirs and assigns, against all and every person or persons, lawfully claiming the .
whole or any part thereof, they will forever WARRANT and DEFEND.
3111 Witll 00 Wberrof, the said part ies of the first part ha ye hereunto set their hands and
seal s this '� day of March A. D., 19 58.
Signed and Sealed in Presence of
...................................................r.....�..r..�..4.:�-.;=:!:�'....a.......::.:.. ,,^...k,� Veal)
Cornelia_T�',Grootenhuts--_-_
rr,Z
:..i...........................�f....; 'tr...:.,. ... .7' .........(Seal)
',Nilma�fan_Someren
__R-obert-_R. Gav_-i—
..............................................................................................................................(Seal)
doe-
....................... .. ...............................................................................................................(Seal)
%tntr of Ulidronl5in,
ss.
.......................Pierce....................................Connty.
Personally came before me, this / 7 day of March A.D., 19 58 ,
the above named Cornelia Te Grootenhuis and Wilma Van Someren
to me known to be the persons who executed the foregoin ' strument and acknowle ed the same..
--R obert
w, ,
Notary Public, .............Piler.c,a............. County, Wisconsin, r
j
My commission expires 10-26 1q �D,,�19, 58
Drafted by .......................R.Qb ert....R.*.....GAAC.,....At.tor.ney-a.t...Law,....S.prirug
N.B.—Ch.54 Wig. Slate,provides that all Instruments to be recorded shall have plainly printed or typewritten thereon the names of the grantors,
.:ante,., -it—...and notary.)
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VOL J48 m-,L
j I � � • v i O Mi i
' � i � +� � t c•S i i 's
INDUS DEPARTMENT 10r, REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTF�}', DIVISION
LA132N AND P.O. BOX 76
HUN RELATIONS PERCOLATION TESTS (115) MADISON WI 537907 9 53707
(H63.09(1)& Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.=0. VISIONNAME:
COUNTY: OWNER'S BUYER'S NAME: IMAILING ADDRESS:
5-T r a" n/, 3010 1C 9 ZZI),,
USE DATtS OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: N TESTS:
Residence �/ /I ❑New Replace I y_jf 7 —.5,— 5 _ Q r7
RATING:S=Site suitable for system. U=Site unsuitable for system V / y
ros ONVENTIONAL: MOUND: IN-GROUNDPRESSURE: S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM: optional)
®U �S ❑U DS [ZU OS 2U ❑S ®ll
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: NX 1 Floodplain,indicate Floodplain elevation: ��
PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH TM,, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
M mo 3.4 A7
B- 5',y2 6,33 ,ZG'� �., ls; � ��
ns":� ,Z2 s /1 ns
30
B-2 • 3' 9#,9,9, Nor/ > 31 F'1815�'�� r� � / 7�� �
B-3 /7 9Y,7�' /►✓ors +
B-
B-
B-
{f PERCOLATION TESTS
TEST DEPTH•. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
1�
NUMBER GNES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PE 3 PER INCH
P- / z•o' 8- 30 a -'710 P- ,Z-o
P- ,O'
P--
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Descri P� i-
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 pent
of land slope.
i
SYSTEM ELEVATION 99ro�
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E
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:
--6 - $-
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
f l ,4 Co;' , �J/Z 3 I 71S-may:301
CST SIGNATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER—
1
I ' (� �✓re✓ S: See. eo
No
N
.130�4�1•t�!/�j �i; .�S�U d 2
�
95 -------- Fx;sty P p
Nose /000 ca 1. r;� P- LY4.3D
,Se p-t o'c
LIJ
ilr�
,L31- �� -33 �� f ��, ; y %'v lR .✓mow B�
33- 94,74
3,MA -Denoics 3enCA 14or T Pump TQnK Go�. Mound
as$m .. De noes Bnro- /lok_S 30 13c�.-n
// f < /0 9� f Area `f&--�mr�BI
P#o - 9e rio f s !fie r G /ro%S �,M La A
Moun t
JQ r•0 ~Den of e s
/mound Area '
� �z �P3
13en c, h Mork /S -",Op of 4611n a3
q�' N� o� barn ,
8'70299
No.
Drawh 13y :
Ayp -4�aZ4
Cs-r 3443
e�ro�e Yl �U�•-�
Page / Of 3
Straw, Marsh Hay, Or
Synthetic Covering
9
Distribution Pipe
Medium Sand
G
Topsoil
E l�
3 p
u
b
% Slope
Bed Of 2M— 2 Force Main Plowed
Aggregate From Pump Layer
D AD Ft.
Cross Section Of A Mound System Using E /4 Ft.
A Bed For The Absorption Area F ,75 Ft.
A �0 G /,O Ft.
Ft. 5 H Ft.
Signed:
License Number: x K 0,'Ft.
Date:
Alternate Posi
of
Force �M,��p'�i`' , .�,� ����� ��k�`' W Z� Ft.
Observation Pipe
0
B K
AI.---------------------- -------_--------=----. -
W L
- ----------•I I
Force Main
o �-------------- ------------
o Bed Of D
2 2
Pipe Aggregate
Observation Pipe Permanent Markers
Plan View Of Mound Using A Bed For The Absorption Area
jil
0f 3
page
rt.
Perforated Pipe Detail
i.
2
i
End View
4.
)Perforoted
End. Cop \t�� PVC Pipe
1.
O� Holes Located On Bottom,
S Are Equally Spaced
< P
+ PV &Sce ain
* Fro p !
{ PVC
Manifold Pipe ■
Distribution —�/ s �,:(, .r Alternate Position Of
Pipe ' ! ;!��jY - , r'� C�� orce Main From Pump
o
Lost Hle Should Be
.: .,
NOW To End Cap
End Cop
Distribution
P ,23
--- _ ----------- ----- R -5,
S " 87p
n , X moo„
2�9
Signed: �, h' x vim- Y IV(--Or 67W COP
Hole Diameter Inch
License Number: ��� �,� Lateral If / Inch(es
Date: - _. - 8-7 Manifold 2 Inches
Force Main 3 Inches
PAGE _aL. OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
—VENT CAP
'i"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MANHOLE COVE
25' FRCM DOOR. 12"MIU.
WINDOW OR FRESH
AIR INTAKE I
GRADE I
4"MIM.
18 M11J.
CONDU�tl
-- ----
18"MIN: \���� ----------
INLET
PROVIDE I -----
"+TIGH ;�SEAL
APPROVED JOINT A ��'j }� yX, '°A'ry,j� I I I APPROVED JOINTS
W/C.Z. PIPE / <lA W/C.=. PIPE
i✓EXTENDING 3 Fa '<;� I EXTENDING 3'
ARM ONTO SOLID Sett_ ONTO SOLID SOIL
3 I ON
{fit`` .�! �• --�
<��?�� ✓.'(a« PUMP-� OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SPEC.IFICATIOUS 8?'O
EPTIC AND �[ ,�9 ('� �,;
OSE TANKS MANUFACTURER: ���` �° S NUMBER OF DOSES. T PER DA-4 9
TANK :,IZE: -_ �DO //��GA/L'LOLIS DOSE VOLUME: 14 5?' G�AAL/LO"S
ALARM MANUFACTURER: TA��Y/�/l Yp CAPACITIES: A= 23 INCHES OR _ 9/ GALLOUS
MODEL NUMBER: _ B= /zf� INCHES OR /- GALLONS
SWITCH TYPE: _ 1,';7e✓c Uri/ C= INCHES OR GALLOUS
PUMP MANUFACTURER: 60611d'
0611 D= 12 INCHES OR zoy GAL LC Q5
MODEL NUMBER: _�' �� �C1�"D �L NOTE: PUMP AND ALARM ARE TO BE
SWITCH TYPE: Ne° _C,aY- INSTALLED ON SEPARATE CIRCUITS
PUMP DISCHARGE RATE - 70'2 GPM
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET
+ MIIAJIMMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . 2.5 FEET
+ FEET OF FORCE MAIN X Z2 Fjo FLFRICTIOAI FACTOR.. 'o- FEET
TOTAL DJNAMIC. HEAD = ,Z/ �2 FEET
INTERNAL D1MEI.ISIOUS OF TANK: LENGTH Z ;WIDTH 7 / ;LIQUID DEPTH �47
SIGNED: Cam, yYt-d'�, LICEI�ISE 1JUMBER: �����9 DATE: �'`� -C/
\o\■■\EM■■■■■■■■■■■■■■■
MODEL 3885
SIZE3/4" Solids,
MENEEMENE
' ■■■■■\�\e■��■■\tee\�■■e■■■■
' ■����■■■■■\�■ice■■►�\�■■■■■
■■■■■■e■e■■■e■■■■■■■■■■erg.
•' ■■■■ee��■■■■■■■■■■■■■■■earl � �
' ■� :iiiiiii�iiiiiiiiiiiii
' ■■■■■■■■■■■►■■■■m■■■■■■■■■
0 rs: See G
eil �e GYOfeh/�u.s fi
No `^
ca •
way
76'
70�
83- ' •a
/ Soo6a1. ,
B,M,,4 •DenoicS 3en ,�/o r" an �o
C/1 /rlA J1 �' Pump 1� 1� eP3 30 13a,-n r G Bales �M,� Q Moun ca �
d
B3
� �enG � �Qr• � j,s %a`a o� �ocsf,�q
of N,l�, cornc�• OP barn . 8702990
NQ•
r
17. �•awr� ,�y
U.�✓�e rr: Sce. !o
/r/e/lG'YOfeh�iu.s fi
No
�• � s:r � N
h
�0�0�6tJ i�f �i; •��UUZ
95� st,
use 000 G°
Way
a.�- -�ao.a'�lev• �
9G"33 xijo
Br.
Off 133- 94,,7wl' _-M•.1.� -Denoies 3enCA /�fprj�'T Mound
ass 0 - 3)eno/CS Bore, /)Ok5 30 13Q fl'T
Pao - Denos Prc A,IeS /09� / Area
Moun of
/QrC4 �enofCS ,ZG�X(o•7
o F3
` L d
G h �pr 1� � q a3
/S �o`u o �o¢yf,hq
A/ N�W� Gorner- oT barn . 8702990
No.
t
- ST. CROIX COUNTY
x r . WISCONSIN
ZONING OFFICE
796-2239 (HAMMOND
)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
.May 7, 1987
Division of Safety and Buildings
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir :
An on site investigation for the Neil Te Grotenhuis property
located in the NE 1/4 of the SE 1/4 of Section 6, T29N-R16W, Town
of Baldwin, St . Croix County, revealed suitable soils at a depth
of 26 inches, below which seasonable high ground water was noted .
This site should be suitable for a mound system.
Should you have any questions regarding this subject, please feel
free to contact this office .
Sincerely,
0, . Kb-,Wn/rc,
Thomas C. Nelson
Zoning Administrator
rc
i
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township/Municipality:
N,_% E S T N/R 8(or W Count
Street Address: Subdivision: y:
Landowners Name: Mailing Address:
/
< P7, l &?./ �
I (He) , the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, .!
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
Signature of Applicant Date
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF ST, CROIX This 6th day of May , 1987 .
l �
Notary Public, State of Wis nsin
John Nestingen
DILHR-SBD-6413 (N. 05/81)
My Co ission E3f UNK: IS PERMANENT.
_ _
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location NE 1/4, SE 1/4, Sec. 6 T 29 N, R 16 W
Town or 3MjW1W Baldwin Street Address Route 1, Baldwin,Wl'- 54002
Lot No. N/A , Block N/A , Subdivision N/A
Landowner's Name: Cornelius TeGrotenhuis
The application for this site is for:
❑ new construction use.
® replacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
❑ to have one of the first five approvals guaranteed for this ;year. This is
number - - of those applications. (Use one of the first five
quota numF—ers i ssuecTyou.)
El one of the applications needing a quota number. The quota number assigned to
this application is - -
❑for one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department.
❑for an application on file prior to February 1, 1980.
❑for a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is
replacing:
❑a failing conventionalksoil absorption system.
❑a holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the lot meets the criteria for a
conventional private sewage system, check here.
I certify that the above information is true and accurate to theft df my
knowledge.
Name Thomas C. Nelson Signature
County Official
Title St. Croix County Zoning Administrator Date May 7, 1987
DILHR-SBD-6158 (R 12/82)
REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
DEPARTMEh r DIVISION
INDUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON,WI 63707
HUMAN RELATIONS (H63.090)& Chapter 145.045)
LOCATION S SECTION: TOWNSHIP/MUNICIPALITY: OT NO.:BL I SUBDIVISION NAME:
/TZ9N/R IJ
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
Sf. 13o e
'
DATES OBSERVATIONS MADE
USE PROF!LE 511,1!111,15,111
P IONS: A ON TESTS:
NO.BEDRMS.: COMMER AL DESCRIPTION:
FWRsidence A/A ❑New .Replace -C'_. cf—g7
RATING:S-Site suitable for system U-Site unsuitable for system
ONVENTI NAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM: optional) 1.
ICEIS 5 �S ❑U ❑S ❑U ❑S CCU ❑S ®U our
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: JV� Floodplain indicate Floodplain elevation:
PROFILE DESCRIPTIONS
R DEPTH UND E TERIINE BACK.)
EXTURE,AND DEPTH
NUM DEPTH , ELEVATION OBSERVED-_I ST TO BEDROCK IF-OBSERVED (S E ABBRVS ON
j M M1"d 0 1 / 3
'' -" I
S B' S'L/Z 6,33 p
30'.
mm� rno
s-3 -I7 9Y,77 /�orJ 3� SSl s,' ° 5" ' ' i�o Bn
g-
e-
B-
PERCOLATION TESTS
�f.
TEST DEPTH, WATER IN HOLE TEST TIME DROP I AT ER LEVEL-INCHES RAPER IINCH ES
NUMBER WG++ES AFTERSWELLING INTERVAL-MIN. —PERIOD D y�
P- ,Z-O Alka e,
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
IN
------------
— I
I
I -
- --
i i
1
I
I I
I I _
I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of-the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
Poe 1, 19 - 5
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
�f l / .4 a lam' , .5yd 3 7/2 5 360
CST SIGNATURE:
/2ua'— 'f'
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —