HomeMy WebLinkAbout030-2014-95-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Building Division St. Croix
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 582037
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. State Plan ID No:
Permit Holder's Name: City Village Township Parcel Tax No:
Janelle Bittman & Brian Goebel TOWN OF SAINT JOSEPH 030-2014-95-000
CST BM Elev: Insp. BM Elev: BM Description:
Section/Town/Range/Map No:
TANK INFORMATION 36.30.19.412E
ELEVATION DATA
TYPE MANUFACTURER A CAPACITY STATION / oBS HI FS ELEV.
Septic ~ ~
w% ♦ Benchmark A= /66
Dosing
72, M., I W eSe~.. 3 3Z0 Alt. BM
lj OJ w p- 1S. /d
r d 16 k t?S Bldg. Sewer
Holding 1(i b
SUHt Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent o Air Intake ` 3 g
Gb~ ROAD 04 W64
~
w; sb u, 137,6 y• 9l'
Septic
1aaa 1 '57 t~ Dt ter-
Dosing f W: es.-. 3Z6 45 4--261 96 3
3 ZD ~ 1 ~ q ~ IJC ~ 3 Header/Man. 4. ~
Aeration Dist. Pipe
~~l • + H'f
Holding Bot. System • ~ b ~Ly
7, V3 13,47 •7to S3 L
PUMP/SIPHON INFORMATION Final Grade
Manufacturer
✓
Demand St Cover ,4
GPM W: I D • a / d
Model Number
TDH Lift ;Friction Loss System TDH Ft
Forcemain LengDia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside !
DIMENSIONS ? Liquid Depth
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: L
INFORMATION G Z ~6
Type Of System: ~ tL CHAMBER OR
p~v e-r p ZT ~f UNIT Model Number:
DISTRIBUTION SYSTEM ,v Header/Manifold i Distribution ~'7+' ~ /27 t~"6 44 ' x Hole Size x Hole S a in
Pipe(s) \ \ _ P 9 Vent to Air ntake
ia
Length 7 D Length Dia Spacing
SOIL COVER ` ~
x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded
Bed/Trench Center it ~?J Bed/Trench Edges xx Mulched
~J Topsoil
No Yes Fa] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:
Inspection #2:
Location: 862 WILLOW RIVER SR I
1.) Alt BM Description = Dk 5~~-' ` Co J ~a. a a G~C rr
2.) Bldg sewer length = EX
- amount of cover =
Plan revision Required? Yes J No
/ / / / c
Use other side for additional information. ( 1 11 0 3 y
SBD-6710 (R.3/97) Date 411nnsseepctorru
Cert. No.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address)- &Z [VI c, 4'o co ~k 0e;f Q located
at: 1/4, 1/4, Section , Town N, Range W
Town of
z1):5 45P~~ , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 1600
Construction: Prefab Concrete Steel Other
Manufacturer (if known): W S
Age of Tank (if known):
Permit number (if known)
(Lic sed Plumber Signature
) (Print Name)
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
~~.ID OTM, ~y County
? - Industry Services D' wn St. Croix
10 1= 7 1400 E Washington itary Permit Number (to be filled in by Co.)
P.O. Box 71
, Madison, WI 53707- ~g Z C)3 7
ST cRoix cou4i'unitary Permit Application State Transaction Number
Ir%~fiiltb.r~L1'~Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address)
purposes in accordance with the Privacy Law, s. 15.04(1 m , Stats. Same
I. Application Information - Please Print All Information gbZ Wl~
Property Owner's Name Parcel #
Janelle Bittmam Brian Goebel 030-2014-95-000
Property Owner's Mailing Address Property Location
Willow River Drive
-4 1 (07- Govt. Lot
City, State Zip Code Phone Number NE 1/4, SW 1/4, Section 36
Hudson, WI 54016 (circle one)
T30N ; R19Eo~
II. Type of Building (check all that apply) Lot #
Z 1 or 2 Family Dwelling - Number of Bedrooms 3 4 Subdivision Name
❑ Public/Commercial - Describe Use Block #
❑ State Owned - Describe Use ❑ City of
CSM Number ❑ Village of
v. y Z Town of I'.mdsm- Sr, 305E"P4
III. Type of Permit: Check only one box on line A. Complete line B if applicable)
A. ❑ New System Z Replacement System ® Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System/Component/Device: (Check all that apply)
® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component ❑ Mound < 24 in. of suitable soil
(explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information: 7D T ENS rti EL FLOW /Lo 3
Design Flow (gpd) Design Soil Application Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
450 Rate(gpdsf) 643 700 93.4', 93.1'
0.7
VI. Tank Info Capacity in
Gallons Total # of 2 o °
Gallons Units Manufacturer w
New Tanks Existing Tanks U w C G.
Septic or Holding Tank 320 1000 1320 1 Wieser/Wieser/Pol lok 525 ® ❑ ❑ ❑ ❑
Dosing Chamber 1 ❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumb re MP/MPRS Number Business Phone Number
John Schmitt 7 L1 223760 715-760-0486
Plumber's Address (Street, City, State, Zip Code)
616 15Wh Ave. Somerset, WI 54025
VIII. Coun epartment Use Only
Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Si ature
❑ Owner Given Reason for Denial $ 7 S" 00 Lt/-& -
IX. Conditions of Approval/Reasons for Disapproval
71U) ~ 1. STEc Q R:
1. Septic tarp; effluent filter and
47-1 L, dispersa#eU.tnust bserviced./ maintained
as per management Plan-provided by plumber.
2. All setback r irements must be maintained
Attach to complete plans for the system and submit to the County only on paper not less thas phEighh9 made/6rdinances
SBD-6398 (R03/14)
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Bittman Goebel Replacement Septic System
Owners Name: Jannelle Bittman & Brian Goebel
Owner's Address 862 Willow River Drive
Hudson, WI 54016
Legal Description: NE1/4, SW1/4, S36, T30N, R19W
Township St. Joseph
County: St. Croix
Subdivision Name:
Lot Number: 4 Block Number
Parcel I.D. Number 030-2014-95-000
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross Section
Page 4&5 Septic Tank Specifications
Page 6 Bull Run Valve Information
Page 7 Filter Information
Page 8&9 Management and contingency plan
Page 10 Existing Septic Tank Certification
Page 11 Septic Tank Maintenance Agreement
Page 12 Warranty Deed
Page 13 CSM or Plat
Attachment Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 11/5/2015 Phone Number: 715-760-0486
Signature: tOl'( G`'~
In round Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1
PLOT PLAN N
Project Name: Bittman Goebel Replacement Septic System
Legal Description: NE1/4, SW1/4, SM3N, W P.I.D: 030-2014-95-000
Subdivision Name: NA Lot 4
Township: St. Jose h Parcel Size: 3.00 Acres SCALE: 1" = 40'
County: St. Croix
Slope: 14% S stem Elevation: T1=93.40' Proposed 70' EZ Flow Trench
A BM1 Elevation: 100.00' To oc tank inspection pipe T2=93.10' Proposed 70' EZ Flow Trench
BM2 Elevation: 99.10' To of existin drainfield vent ca Existing Drain Field=18' X 38' Rock Bed
~ Backhoe Pits:
S7=Existing 1000 gallon Wieser Se tic Tank
S2=Pro osed 320 gallon Wieser Se tic Tank
NOTE: See CSM for a complete view of the parcel.
4 inch Sch 40 -ASTM D2665
4 inch 3034 - ASTM D3034
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Page 2
SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT
Project Name: Janelle Bittman & Brian Goebel
Gravelless Leaching Unit Specifications
Manufacturer Model Laying Length EISA Rating
Infiltrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
System Sizing
EISA Rating per Foot of EZ Flow 5 ftz Soil Application Rate 0.7 gpd/ft2
450.0 gpd Design Flow : 0.7 Soil Application Rate = ~ EISA = 128.6 Feet of EZ Flow
F-2 ~ trenches 65 feet long each
2 No. of Cells 7 Per Cell
3 ft Cell Width 14 Total No of 1203H
70 ft Cell Length 350 sq ft EISA Per Cell
3 ft Cell Spacing 700 sq ft Total EISA
Typical Cross Section
Finished Grade 97 ft Observation Pipe with
approved cap or vent
Soil Backfill
■
■
,
36 inch
■ ■ Geotextile Fabric
■ ■ s
12 inch o (I ~ j Slotted and Anchored VentlObservation Pipe
with Cap
93.40ft O
93.1 ft Infiltrative Surface
>36 inch
90.03 ft Limiting Factor
• • ■ ■ ■ , , , , 88.08 ft Limiting Factor
Plumber/Designer Signature: n-r
License MPRS 223760 Date: November 5, 2015
Page 3
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Page 5
American Manufacturing Company Bull Run Valve Page 1 of 3
4
f
Home About Site Map Order Info Training Videos Contact Drip Systems
Treatment Controls Products Downloads Design Guidance
THE BULL RUN TM VALVE
'WATER-TIOW
x a W•ACCESS CAP
1g 8ER CAP
ADAPTER
R18ER
TUBE
VALVE DIF EC114N
HANDLE
The Bull Run Valve TM is designed to split flows to septic
fields or systems. In addition to the advantages of f OVrPORr
longer life and easier installation it is the most public C OUTPORT
health safe alternating device available for wastewater
disposal applications. The use has absolutely no contact
with wastewater due to the valve's leak-proof and
external operating characteristics. The change over from f IN PORT
one drainage field to another can be accomplished in
less than a minute by simply turning the valve without
digging or contact with wastewater. The Bull Run Valve is available in 4" sch 40 pvc
and is suitable wherever septic disposal systems
are used - in commercial, industrial, and
residential applications.
OPERATING THE VALVE
The direction control handle should be rotated
Fuld Fuld Field Fiaid periodically to direct effluent to one or the other
No.1 No.3 No.1 No.2 of two septic fields. After removing the screw
cap at the top of the riser tube, the valve handle
valve Valve can be turned with the valve key furnished.
Pasitioaed Po»<iYOOCd BULL RUN VALVE
on No. 1 °nN0'2
during &zing Complete Valve Kit
Old Yeats Septic Septic Even Years Contains
Taok Tack 1. Bull Run Valve body
2. 28" Valve Key
3. Riser Cap Adapter
ITEM DESCRIPTION 4. Watertight Access Cap
BRV4 BULL RUN VALVE 4"
Page 6
file:///C:/Users/John%20Schmitt/Desktop/John/American%2OManufacturing%20Company%20--%2OBull%2... 11/4/2015
P43LI ~Inc.
Ar-
Innovations in Precast Drainage Zabel' PL-525 Effluent Filter
& Wastewater Products A Division of Polylok Inc.
PL-525 Filter
The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has
525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball
installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off
the system so the effluent wor t leave the tank.
Features: 1/16" Filtration Slots
• Rated for 10,000 GPD (gallons per day). Alarm Switch
10 000 GPD (optional)
• 525 linear feet of 1/16" filtration. ,
• Accepts 4" and 6" SCHD 40 pipe. G Accepts 1" PVC
Extension Handle
• Built in gas deflector.
• Automatic shut-off ball when filter is removed.
• Alarm accessibility. Rated for
10,000 GPD
• Accepts PVC extension handle.
PL-525 Installation:
Ideal for residential and commercial waste flows up to 525 Linear Ft.
10,000 gallons per day (GPD). of 1/16"
Filtration Slots
1. Locate the outlet of the septic tank.
Aw-
2. Remove the tank cover and pump tank if necessary. ,
3. Glue the filter housing to the 4" or 6" outlet pipe. CHD If SCHD 4" & 6
40 pipe
the filter is not centered under the access opening use a 7:µl
Polylok Extend & Lok or piece of pipe to center filter.
4. Insert the PL-525 filter into its housing.
5. Replace and secure the septic tank cover. Certified to
NSF/ANSI Standard 46
PL-525 Maintenance:
The PL-525 Effluent Filters will operate efficiently for
several years under normal conditions before requiring
cleaning. It is recommended that the filter be cleaned
every time the tank is pumped, or at least every three
years. If the installed filter contains an optional alarm,
the owner will be notified by an alarm when the filter
needs servicing. Servicing should be done by a certified Gas Deflector
septic tank pumper or installer. Automatic
1. Locate the outlet of the septic tank. Shut-off Ball
2. Remove tank cover and pump tank if necessary.
3. Do not use plumbing when filter is removed.
4. Pull PL-525 cartridge out of the housing.
5. Hose off filter over the septic tank. Make sure all
solids fall back into septic tank.
6. Insert the filter cartridge back into the housing malting
sure the filter is properly aligned and completely inserted. Polylok, Outdoor Zabel l & & Best filters t Alarm Extend i Lall rM
accept Easily installs
7. Replace and secure septic tank cover. the SmartFilterg switch and alarm. into existing tanks.
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
Page 7
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner: Janelle Bittman & Brian Goebel Tank Manufacturer: Wieser Concrete NA
Permit # E Septic E Dose Holding Volume: 1000 gal
DESIGN PARAMETERS Tank Manufacturer: NA
Number of Bedrooms: 3 177 NA 1Septic Dose Holding Volume: 320 al
Number of Public Facility Units: ✓NA Vertical Distance Tank Bottom (s) to Service Pad: ft
Estimated (average) Flow: 300 gal/day Horizontal Distance Tank(s) to Serivice Pad: ft
Design (peak) Flow = estimated x 1.5: 450 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if
In Situ Soil Application Rate: 0.7 gal/day/ft2 horizontal is > 150 feet. Specific instructions to be provided on back.
Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: POLYLOK
Fats, Oils & Grease (FOG) 530 mg/L Effluent Filter Model: 525 NA
Biochemical Oxygen Demand (BOD5) 5220mg/L NA Pump Manufacturer:
Total Suspended Solids (TSS) 5150mg/L Pump Model: NA
High Strength Influent/Effluent Monthly average Petreatment Unit
Fats, Oils & Grease (FOG) 530 mg/L Manufacturer:
Biochemical Oxygen Demand (BOD5) 5220mg/L NA I- Mechanical Aeration Peat Filter
Total Suspended Solids (TSS) 5150mg/L 'ANA
Disinfection r! Wetland
Petreated Effluent Monthly average r Sand/Gravel Filter ' Other:
Biochemical Oxygen Demand (BOD5) 530mg/L Soil Absorption System
Total Suspended Solids (TSS) 530mg/L -;'NA r✓ In-Ground (gravity) In-Ground (pressure)
Fecal Coliform (geometric mean) 5104cfu/100ml t At-Grade Mound NA
Maximum Effluent Particle Size: Y in dia. N r Drip-Line Other:
Other: Other: NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
When combined with sludge and scum equals one-third of tank volume
Pump out contents of tank(s) When the high water alarm is activated
Inspect condition of tank(s) At least once eve : 3 myea~~sj
(Maximum 3 ears) 177 NA
Inspect dis ersal cells month(s)
p At least once every: 1.5 I"✓ year(s) (Maximum 3 years) NA
Clean effluent filter r month(s)
At least once eve : 1.5 fV year(s) NA
Insect Um month(s)
p p um pump controls & alarm At least once every: r. year(s) (o NA
h s
Flush laterals and pressure test At least once eve
ry: montyear(s) NA
Other: Turn off Bed Use T1 & T2 for 5 ✓myee ~s)
NA
Other: Alternate Drainfields Alternate Drainfields every 1.5 years
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
Plumber; Master Plumber Restricted Sewer; POWTS Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank
inspections must include a visual inspeciton of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on ground surface. The
dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. The ponding of effluent on the ground surface may indicated a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumualtion of sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Admininistrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment units,
and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
(Rev.2/05)
Page 8
START UP AND OPERATION Page of
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are
detected have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain
(sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely
abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for
a code compliant replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil
and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their
permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to
replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Name: John Schmitt Name: John Schmitt
Phone: 715-760-0486 Phone: 715-760-0486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name: Name: St. Croix County Zoning
Phone: Phone: 715-386-4680
This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Use of this document does not guarantee the performance of the POWTS.
P190. 905)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 862 Willow River Drive
at: NE '/a, SW '/a, Section 36 30 located
Town N, Range 19 W
Town of St. Joseph , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service 11/2/2015
Did flow back occur from absorption system? Yes No x
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 1000
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): Wieser Concrete
Age of Tank (if known): 29
Permit number (if known) 79153
John Schmitt
(Licensed Plumber Signature) (Print Name)
MPRS 223760
(Title) (License Number) MP/MPRS
11/5/2015
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
Page 10
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
owner/Buyer Janelle Bittman & Brian Goebel
Mailing Address 862 Willow River Drive
Propel ty Address 862 Willow rRiver Drive
(Verification required from Planning & Zoning Department for new construction.)
City/State l-ludson, Wl Parcel Identification Number 03O-2014-95-400
LEGAL DESCRIPTION
Pro NE /4 SW 36 30 19 St. Joseph
perry Location -1/4 1/4 , Sec. , T N R W, Toxvn of
Subdivision Plat; y Lot # 4
Certified Survey Map # Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house OvesOno Lot lines identifiable EI1=es[]no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2} after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
l'w°e, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of myiour knowledge. Uwe amiare the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms 3
~f~rr 0l~
SIGNATL OF A PLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
Page 11
S..K II•.
Department of SOIL EVALUATION REPORT
p Safety and #1803
s Professional Services in accordance with Comm 85, Wis. Adm. Code Page 1 of 4
Schmitt Soil Testing, Inc.
Attach complete site plan on paper not less than 8%x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
Please print all information. 030-2014-95-000
Personal information you provide may be used for secondary purposes (Privacy Reviewed By Date
Law, s. 15.04 (1) (m)). L~~~(!
Property Ownerd
Property Location
Bittman, Janelle/Goebel, Brian Govt. Lot NE1/4, SWIM, S36, T30N, R19W
Property Owners Mailing Address Lot # BT lock # Subd. Name or CSM#
862 Willow River Dr 4 CSM 4/1114
City State Zip Code Phone Number
Hudson ❑ City ❑ Village ❑ Town Nearest Road
54016 St-Joseph Willow River Dr
❑ New Construction Use: ❑ Residential / Number of bedrooms 3
Code derived design flow rate 450 GPD
Replacement ❑ Public or commercial - Describe:
Parent material Outwash (Onamia Series) 2~
General comments Are is suitable for a conventional system with a 0.7 Flood plain elevation, if applicable NA fl•
and recommendations: gpd/sgft rate. Possible system elevation for replacement area is 93.4' (High
Trench), 93.1'( Low Trench). Slope of area is 14%.
F 1-1 E" Boring # ❑ Boring
Pit Ground surface elev. 95.70 ft. Depth to limiting factor 96+ in.
Horizon Depth Dominant Color Redox Description Soil Application Rate
Texture Structure Consisten Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
"Eff#1 "E02
1 0-11 10yr3/3 none sl 2msbk mvfr as 2m,2f 0.6 1.0
2 11-15 7.Syr4/4 none grsl 2msbk mvfr gw 2m,2f 0.6 1.0
3 15-22 7.5yr4/6 none grls Osg ml gw 2f 0.7 1.6
4 22-38 7.5yr5/6 none grcos Osg ml a 0.7 1.6
5
38-96 10yr6/4 none s Osg ml
L
2] Boring # ❑ Boring
Pit Ground surface elev. 98.45 ft. Depth to limiting factor 101+
in. Soil Application Rate
Horizon Depth Dominant Color Redox. Description Texture Structure
in. Munsell Qu. Sz Cont. Color Consisten Boundary Roots GPD/fl2
Gr. Sz. Sh. 'Eff#1 'Eiii
1 0-15 10yr3/3 none sl 2msbk mvfr as 2m,2f 0.6 1.0
2 15-22 10yr4/4 none grsl 2msbk mfr
9w lvf 0.6 1.0
3 22-45 7.5yr5/6 none grcos Osg ml
9w 0.7 1.6
4 45-101 10yr6/4 none s Osg ml
" Effluent #1 = SOD? 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2 = BOD5 <_30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature:
CST Number
Thomas J. Schmitt
~:~4A&--
Address Schmitt Soil Testing, Inc. 227429
1595 72nd St. New Richmond, WI 54017 Date Evaluation Conducted Telephone Number
11/2/2015 715-760-1978
SBD-8330 (207/00)
Property Owner Bitt_man, Janelle/Goebel, Brian Parcel ID # 030-2014-95-000
Page 2 of 4
[i] Boring # Boring
Pit Ground surface elev. 96.50 ft, Depth to limiting factor
101+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
*Eff#1 *Eft#2
1 0-9 10yr3/4 none si 2mgr mvfr CS im,3vf 0.6 1.0
2 9-22 7.5yr5/6 none grcos Osg ml gw ivf 0.7 1.6
3 22-94 10yr6/4 none s Osg ml
0.7 1.6
❑ Boring
Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor
in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
*Eff#1 *EtT#2
Boring # [I Boring
U Pit Ground surface elev. ft. Depth to limiting factor
in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
*Eti#1 *Eff#2
* Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30 <150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS <30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (R.07/00)
Schmitt Soil Testing, Inc.
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Page 3 of
Schmitt Sons Exclvatiog Inc.. Name: i Ja `Ile ittnan/rinn G~ebei
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Adidrels D r
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- - Eit; state, i zip
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~X15-I54b25
Phone: r
60 197
PIS: ~ X030-2014-95-000
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SOIL PROFILE DESCRIPTION
Owner CST:
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System Eiev. Proposed: ft Syst. Range q3, y ft to )~3 /ft Ld Rate: .7
# Z Elevation: fS - # 3 Elevation: ~6.~d I g~ 70
# / Elevation:
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Form -STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP s SEC._ T,_N-R•~
C& ST. CROIX COUNTY, WISCONSIN
ADDRESS
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IMR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ovER Co' -7n /✓oaYN
/InoPE(LTY LSNfi
fjf PA.P frn WELL
ga~
~'XZSTZrvG /tESsl~~rvGL" ~ Exrsn~c~
I i GAkA&E
P~~o o DA \,,y
55 16.5
.38
\ O E-)000 GAL. IEP)2L -MNWC
0
t
100'ro CAS-r
pkaeaTy LSNE-
-
SLOPE
0 ChT STAGIL
1/
i ❑~i3./n7 rS ToP
A0 T 0 of PLED
I.iEST I°/+oP6/tTY LZivE T Parr ELEVc
' /00,00
)9o' to Souill
/-Pion62tY L2A/G
/va scALE ,
INDXCAT NORTH ARROW
BENCHMARK: Describe the vertical reference point used T po_cT /rrF- a: OF 62Axi rxF,6
Elevation of vertical reference point: -1W,00 Proposed slope at site: G U
SEPTIC TANK: Manufacturer: .,~12 Liquid Capacity:
Number of rings used: _ Tank manhole cover elevation: A. 6/D
Tank Inlet Elevation: Tank Outlet Elevation: 2o-z2
Number of feet from nearest- Road.: Front,O Side ,O Rear,
(D 2L
feet
4.; From "nearest - property line Front 10 Side 10 Rear, 0 1 / U feet
Number of feet from: well building:
6
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
y
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: / -j Trench
Width: -/6 Lenith: Number of Lines: Area Built:-A 6
Fill depth to top of pipe: Ya_f
Number of feet from nearest property line: /;Frront, O Side, Rear,O Ft.
Number of feet from well: d5
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
ell
License Number : ~'7_( ?O (Z
3/84:mj
w
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer:
Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear ,(D Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Len th:
• Number of Lines: Area Built:
Fill depth to top of pipe: ya ~f
Number of feet from nearest property line: Front, O Side, Rear, Ft.ZG~
~
Number of feet from well: ~ O
Number of feet from building: 4l'?, S
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
W41
Dated: Plumber on job:
License Number: f"J ?Oy
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
MADISON, WI 53707 BUREAU OF PLUMBING
CONVENTIONAL OALTERNATIVE State Plan I.D. Number:
~
❑ Holding Tank O In-Ground Pressure 1:1 Mound (lfassigned)
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Pat Thomas Rt. 5, Box 72, Hudson, WI 54016
4 -13 0V 'V - / 4/ rn
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. LEV.
NE SW, Section 36, T30N-R19W, Town of St. Joseph, Lot#4
Name of Plumber: JMPIMPRSW No.. County Sanitary Permit Number:
Gary Zappa 3300 St. Croix 79153
SEPTIC TANK/HOLDING TANK: r
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNIDNG LABEL IL OC OKIYNGES COVER O
, / 9 ^ i PROVIED. PROVIDED-.
!r NO
BEDDING: VENT DIA.: / VENT MAT I HIGHWAY H YES C~ NO
/I ALARM NUMBER OF ROAD. PROPERTY WELL . BUILDING: JAIR VENTTOFRESH
FEET FROM ®V LINE INLET
IYES ONO OYES ONO NEAREST 0
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL 1PUMP,SIPHON MANUF ACTIIEtEH WARNING LABEL JLOCKING COVER
PROVIDED. PROVIDED:
DYES ONO DYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PH OPEH7V WELL BUILDING VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET.
PUMP ON AND OFF) OYES ONO N J 1,/,S-
SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing IMAMFTEH IIIATIHIAI 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:
LENGTH INO OF JUISTH PIPE SPACING COVER JINSIDE UTA 'PITS LIQUID
BED/TRENCH WIDTH
1 / THEN S EHIAL^ PIT DEPTH
DIMENSIONS
%
GRAVEI 1)F F'iH FILL DEPTH J(FftV T H. PIPE UISTH PIPE DISTR. PIPE MATERIAL STH NUMBER OF PROPERTY[ WELL ~y BUILDING: VENT TO FRESH
BELOW PIPES
41 ABOVE COVER IINLFQt ELE V.ENU P FEET FROM LIN / AIRI ETA
7 f 0 f NEAREST-- DO
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-
OYES NO meets the criteria for medium sand. TIONS MEASURED.
O
SOIL COVER TEXTURE PEHIAN[ NT MARKI HS OBSERVATION WELLS
OYES ONO OYES ONO
DEPTH OVER TRENCH BED DEPTH OVER THENCH BED DEPTH If TOPSOIL SODDED SEE UE II MULCHED
CENTER EDGES
OYES ONO OYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. 7LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH HE LOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV. CIA. ELEV. PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE:
DYES ONO OYES ONO NEAREST _7~
Sketch System on Retain in county file for audit.
Reverse Side.
SIQNJATU E TITLE.
7
DILHR SBD 6710 (R. 01/82)
ujisconsin APPLICATION FOR SANITARY PERMIT
D I L H R COUNTY
- OEPggT ienT OF
(PLB 67) UNIFORM SANITARY PERMIT #
- Ir7OU5TgV,LRBOg6 MUTgl"IgELFiTl01'IS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
11/0 T rl 1 ~u , S y
PROPERTY L CATION C1T9':
IY~ 14/4, S , TV N, R € (or) W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE O LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
■ 1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
5d New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
9 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued -
El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity DD C1 J
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Vs- 4 4? ® Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: /MPRSW No.. Phone Number:
G 5S9 .3 O4 1(21S)jVK So
Plumber's Address: Name of Designer:
o zo
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~~oZf pd ❑ owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
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"), 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
Location of Property STGU k Section C~
Township S%. ~/~OS
Mailing Address
Subdivision Name
Lot Numbery
Previous Owner of Property ~%pff,~/ ~~VS
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable?
Yes No
Is this property being developed for resale (spec house) ? Yes
7-' 9 X67 No
Volume and Page Number as recorded with the Register of Deeds
717CMT;`WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
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
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) ceAt 6y that a t statements on thi.6 6ohm an.e thue to the beat of my (ouA)
knowledge; that I (we) am (ah.e) the ownea (s) os the pnopenty de,6n bed in -th.Zs
in6on.mation john, by vi tue o6 a wa&4anty deed neco&ded in the Oj6ice o6 the
County Registeh of Deeds as Document No. / and that I (we)
phesentty own the phoposed site Ooh ,the sewage poi at system (on I (we) have
obtained an easement, to hun with the above descni.bed phopehty, 6oh the
constAuction ob said system, and the same has been duty neco)Lded in the 06jice
o6 the County Regizteh ob Deeds, as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
I~ I
y
DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
QFFIC~
J~eacE ST. CROIX CO.,
Wis.
467---
Rac'd. for Ierord this 14th
t John A._Leys a/k/a John Adrian Leys and as John Leys day of May A.D. 19 86
- A4 1;30 P. ~ ~ -
James O'Connell
conveys and warrants to .._.Patrick_ D._-Thomas__and Susan M. leis Hof and
-Thomas,...husband- nd wifa 1QZnt tenants
Kathleen Walsh! Deputy
RETURN TO
ii
_
-
j the following described real estate in St. Croix I_
County,
State of Wisconsin:
Part of the East Half of the Southwest Quarter of Section Tax Parcel No
36, Township 30 North, Range 19 West, described as Lot 4
of the Certified Survey Map recorded and filed in the office of the Register of Deeds
for St. Croix County, Wisconsin on September 30, 1981 in Volume 4, C.S.M., Page 1114,
Document #373626 SUBJECT TO the private easement over the South 33 feet thereof as
shown on said map.
i !
' TOGETHER WITH a permanent non-exclusive easement to use as an access road and for the
installation of utility lines so located as not to interfere with use for road purposes,
the 66 foot wide strip of land marked "Private Easement" on said C.S.M. and on the
Certified Survey Map recorded and filed in said office of the Register of Deeds on
the same date in Volume 4, C.S.M., Page 1115, Document 4373627.
The costs of maintenance of the private access road shall be shared pro rata by the
adjoining property owners in accordance with the roadway statement contained in C.S.M.
44373627 filed 9/30/81 in Volume 4, Page 1115, St. Croix County, Wisconsin. Buyer
shall pay not more than 1/5th of private road maintenance costs until land South of
I " those portions of the road easement described as running N78°02'55"W and S89°25'10"W
are subdivided or built upon.
This deed is given in satisfaction of the land contract between the parties recorded
May 24, 1985 in the office of the Register of Deeds for St. Croix County, Wisconsin
in Vol. 712, Pages 562-563, Document 44402212. TPANSF21h
This -_..1.5.-11at............ homestead property.
Uvj (is not) ~t7`-+
~'FF
Exception to warranties: all existing easements of record, the road easement as
stated in the description and the maintenance provisions contained in the C.S.M. filed
i 9/30/81 in Volume 4, C.S.M., Page 1115, Document 41373627; any lien or interest created*
Dated this ~!~(/-~h.---•----•---••------ day of __..March.....-- 19.86-..
*by the act or default of the grantees, if an
j ------------•----•------•---------•---•-------------•----..(SEAL) - .(SEAL)
eohn A. Ley
.................................•-----•-•--------•..----...(SEAL)
(SEAL)
i ,
it
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
ji
ss.
ST. CROIX
County.
authenticated this day of___________________________ 19 Personallcame before me this .day of
March 19.86.. the above named
JohnA. L
eys......................................
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
authorized by § 706.06, Wis. Stats.)
to me known to be the person who executed the
j foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
John D. Heywood. HEYWOOD CARI & MURRAY
i P.O. Box 229; Hudson, WI 54016 * -
Notary Public St. Croix County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date:E_
//er-7....................... 19----•-•-•)
*Names of persona signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSTN V;'isrnnain Lelcnl Blnnk Inr
H
cn
H
a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
OWNE BUYER,/~~
ROUTE/BOX NUMBER Fire Number
.CITY/STATE ZIP
PROPERTY LOCATION:_S'f6J fit, ;4, Section, T_. 0 N, R1_W,
Town of St. Croix County,
Subdivision 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,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior.to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all 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
three year expiration. yo
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ro
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.
SIGNED
DATE `L
f '
St. Croix County Zoning Office
P.O. Box 9ak
Hammond, WI 54015
715--796-2239 or 715-425-8363
Sign date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115 'P.O. BOX7969
HUMAS: RELATI S )
MADISON, WI 53707
i (1-163.090) & Chapter 145.045)
L ATION5 SECTION: T OWNSHI JalUNteT1s7MITY: [OT~0.]BI-K. NO.': SUBDIVISION NAME:
114w11 3b /1 Oil for `
COU • Y: OW 'S B YER'S NAME: MAI I A DR SS:
~Voi fi g Coy.,
USE DATESO WRVATIONS MADE
y NO.BEDRMS : COMMER DESCRIPTION: PROFILE ~TI NS: A N TESTS:
Olesidence 3 /t~ Xew ❑RePlace Z 5' g
I•
RATING: S- Site suitable for system U- Sittee unsuitable for system OUND: WE MNS ❑U IN, 2 S oU ❑ M ou L ❑ SG TANK: RECOMME En~3e r7Mna1)
If Percolation Tests are NOT required DESIGN RATE: ` I If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: C` Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHYS-T TO'BEDROCK IF OBSERVED (SEE'ABBRV. ON BACK.)
B-
g_ ~l G (e o t, ~ole_
D410-
B-3
6- s
B-
B-PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES, AFTER ELLING INTERVAL-MIN. PERIOD I D PERIOD PER INCH
P_ i o" 3 G - 6 3
P_ 2. 501, 3 < 3
P 3 3
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 7 2, 1 7
1
' - ~ I rr ` f ' Zvi
tN
1, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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): n TESTS WE E C MPLETED ON:
'G ac,~ ~ G S g 6
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBE (optional):
3 44" 5 341, (01631
CST51rpN U E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) OVER -
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,- ' DIVISION
LABOR AND
P.O. BOX HU AN RE! ATIONS PERCOLATION TESTS (115) MADISON W 53707
(H63.090) & Chapter 145.045)
LOCATION: , ' N: TOWNSHIP/MUNICIPA OT N .:BLK NO.: SUBDIVISION NAME:
~ITY:
H (
5/S ' 3~/T3a /R 9 o Y/ 170-seo
COUNTY: OWN 'S BUYERS NAME: MAILI ADDR SS:
a d& ' e R 5 Covw• T& A
USE DATES SERVATIONS MADE
N0. B : CO M R TIO NS: 1PERCOLATION STS:
Residence ;lew ❑Replace .512
RATING: S- Sits suitable for system U- Site unsuitable for system tl~G /
❑ nail
V S Ou . MOS. ❑u IN-GSOUNS F~ rYSTEM-IN-FILLIHOLDING TANK: RECOMMENDEDl TEM~op io
U SS (I~}o L/, T
If Percolation Tests are NOT required DESIGN RATE:
tf any portion of the tested area is in the
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL P H T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION B TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.)
B- > / ..11r' C/ S;.83' "L-S 5~,-S r JVr
B- 3 g 93,2
' N s/• , 9a' / w ~a • . s
B- y '7 V O 96 ~ A .2e.f
B-
r r ' i t r
175'8/ 52,o', 73 13, 1
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES• AFTER SWELLING IN ERVAL-MIN, PERIOD PER I H
P-So d' nr- 1A4 J"- ~+o
P- .
P_ 11% he- 9DIV
P
P- S f
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 7
t
0__-6 - --1---
Ltl
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.
J...
I
R
E COMPLETED ON:
NAME print : r TEST72,:,dis
ADDRE CER IFIC ION NUMBER: PHONE NUMBER (optional):
3 Qo 33 ~H sue. U• o/` C 307 1~ 3 6 6 s 3
CST I A
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) --OVER -
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vo Cnuss
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Parcel 030-2014-95-000 02/06/2007 M
1 OF
Alt. Parcel 36.30.19.412F 030 - TOWN OF SAINT JOSEPH
Current k ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-owner
O - BRUHN, DAVID E & PATRICIA ANN
DAVID E & PATRICIA ANN BRUHN
862 WILLOW RIVER DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 862 WILLOW RIVER DR
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE
SEC 36 T30N R19W NE SW & SE SW LOT 4 OF Block/Condo Bldg:
CSM 4/1114 EXC TO TOWN RD 1095/630
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
36-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1095/630 QC
07/23/1997 897/01
07/23/1997 39/467
07/23/1997
2007 SUMMARY Bill Fair Market Value: Assessed with: j,~ P`Jr< u<
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 123,200 191,000 314,200 NO
Totals for 2007:
General Property 3.000 123,200 191,000 314,200
Woodland 0.000 0 0
Totals for 2006:
General Property 3.000 123,200 191,000 314,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 138
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
~A
S 504458
/yam This instrument drafted by Fran 8leskacek Pro'.
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9 Page 2674 St. Croix Co" VVi
1 FORM NO. 985•A
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TIRED SURVEY MAP
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VOL. 4 PAGE 1114 I o Z,; ,
~m 1
o C ;RTIFISD SUKVLY i~111PS ' I o
Z ST. CaOIX COUNTY9 WI• /
mr
tD
ST. CROIX COUNTY
WISCONSIN
ti ZONING OFFICE
o x NP If u x n x - .,■„b ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
_i
November 29, 1994
Kernon Bast h~mm g
Edina Realty
400 South Second Street 77 G
Hudson, WI 54016 ~~o• 3 v' ~f , Z F
RE: Water Results for Brian & sandy Graff
Address: 862 Willow River Drive, Hudson, Wisconsin
Dear Mr. Bast:
Enclosed is the original test results from Commercial Testing
Laboratory, Inc. for water inspection of the above property. If
you have any questions regarding these results, please do not
hesitate in contacting our office.
incerely,
Ctn~
Mary Jenkins
Assistant Zoning Administrator
js
Enclosure
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730 st~
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030 n
ST. CROIX COUNTY ZONING OFFICE REPORT NO.! 74613/01 PAGE 1
ST.CROIX CTY GOV.CTR RFPORT DATES 11/25/94
1101 CARMICHAEL ROAD DATE RECEIVERS 11/22/94
HUDSON, WI 54016
ATTNS THOMAS Co NELSON
OWNERS Brian It Sandy Graff
LOCATION; 862 Willow River Dr., Hudson
i
COLLECTOR: M. Jenkins
~
DATE COLLECTEDS 11-21-94
TIME COLLECTEDS 3S30pm
1
SOURCE OF SAMPLE. Outside faucet
i
DATE ANALYZED.11-22-94
TIME ANALYZED4#2S00pm
COLIFORM,MFCCS 0 /100 ml.
INTERPRETATIONS Bacteriologically SAFE
NITRATE-NS 2 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 mi a1-~
Nitrate-Nitrogen, mg/L
LAB TECHNICIAN. Pam Gane u~$
WI Approved Lab No. 19,E
RESUL)7,},
f oF,NOEVENpEN FAX.'D OIL...
J9A PHON!'FD ON:
CALLS _
ZJ"~ .~r A { Means "LESS THAN" Detectable Level Approved by'
0
PROFESSIONAL LABORATORY SERVICES SINCE 1952
31/28/04 MON 11:55 FAX 1 715 962 4030 COMM. TEST LAB 16 001
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST.' CROIX COUNTY ZONING OFFICE REPORT NO.: 74613/01 PAGE 1
ST.CROIX CTY MICTR REPORT DATE: 11/25/94
1101 CARMIICHAEL ROAD DATE RECEIU®: 11/22/94
HUDSON, NI 54416
ATTN: THOMAS Co NELSON
OWNER: Brian b Sandy Graff
LOCATION: 862 W!I.Loe River Dr., Hudson
CMI,.ECTOR: M. Jerk i Mrs
DATE COLLECTED; 11-21-94
TIME COLL.ECTEDS 3:30pm
SOURCE OF SAMPLE: Outside faucet
DATE ANALYZED:il-22-94
TIME ANALYZED:2:00pm
COLIFORM,t M: 0 /100 at
INTERPRETATION: Bacteriologically SAFE
NITRATE-N: 2 PPe
Above 10 PPm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml.
Nitrate-Nitrogen, mg/L
LAB TECHNICIANt Pam Gene
WI Approved Lab No. 19
S,
RESULT,.
FAX'0 ON' '
pHON50 ON:
CAL_LER:..~.r
V
Means "LESS THAN" Detectable Level Approved by:
PROFESSIONAL LABORATORY SERVICES SINCE 1952
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
"r""""" ST. CROIX COUNTY GOVERNMENT CENTER
, 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
November 17, 1994
Mr. Kernon Bast
Edina Realty
400 South Second Street
Hudson, Wisconsin 54016
RE: Septic Inspection for Brian and Sandy Graff
Address: 862 Willow River Drive, Hudson, Wisconsin
Dear Mr. Bast:
An inspection of the septic system for Brian and Sandy Graff's
residence located at 862 Willow River Drive, Hudson, Wisconsin, was
conducted on November 16, 1994.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Also, water samples were taken. Once we receive the results we
will forward the same on to you. Should you have any questions in
the meantime, please do not hesitate in contacting this office.
Sincerely,
Mary ql./~6nkins
Assistant Zoning Administrator
mz
~I'L
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
r r N o n r r r■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
All Hudson, WI 540 1 6-771 0
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
A lease specify desired test(s) & remit appropriate fee with
-
application. Outside water lines are often turned off during
winter months, making access to the home necessary. Please make
U arrangements with this office to insure that entry can be gained.
( Water (VOC's) $185.00 12 Septic $50.00
/,"Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria
retest $15.00
` Owner: 0A*) 4 ~Qi4Fi~ Requested by:
1 Address: 9'&a (c),j!5/2 OR Address : 050
rJD3oc~ ZIPS G/o0 5, ZIPl~
Telephone Ng: ( ) S~Q-/ate! Telephone N4: ( )-~a3fo
Property address Fire If & Street) ItA f 1 Oco c uige-
pv Location: Sec. , T - N, R W, Town of 77 OS,E
Realty irm:~104 Lock Box Combo: Closing Date: ll -oZr 94
Zl_
1 ^J TO BE COMPLETED BY PROPERTY OWNER
M PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Na I
Water sample tap location: YOUR hi S0RE7_,&~o
Is the dwelling currently occupied? 41--Yes ❑ No
If vacant, date last occupied: A&A
Age of septic system: S'^ y,Ps .
Septic tank last pumped by:~(~ Date: 103
Previous Owner's Name(s) : t,~NK~oc~U
Have any of the following been observed?
❑Y Mlf" Slow drainage from house.
❑Y RT Sewage Back-up into dwelling.
❑Y B1l- Sewage discharge to ground surface or road ditch.
❑Y CN Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE:i'✓`' DATE•--7~
1/94 A _~L.
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IN
O
0
TO BE COMPLETED BY INSPECTION A ENC -
System design &/or permit on file? ❑Yes ONo
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: EJBelow grd ❑At-Grd OMound
Approx. size 'X 66ravity ❑Dose OPressurized
Ft.2 ❑Bed ❑Trench ❑Dry Well
Molding Tank OOutfall pipe
OBSERVED DEFICIENCIES OOther OUnknown
Septic tank
Setbacks: OHouse ✓ OWell✓ OProp. line OOther
Dose tank
Setbacks: ❑Ho; OWell rop. i OOther
OLocking covo-r ❑W ing label OPump/Floats
OAlarm Elec. ing
Soil Absorption System
Setbacks: OHouse\/ OWellV_ OProp. line ✓ ❑Other
OPonding: /h-elr ~ li-e ODischarge:/yL6W,
General comments:
INSPECTORS SKETCH F SYSTEM LOCATION
N
Inspe t r -
-
T itl
i