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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: Trench:
Width: T�� Length: Number of Lines:__ Area Built:-2k
Fill depth to top of pipe:
Number of feet from nearest property line: Front O Side, Rear, Ft . 2k
Number of feet from well: y,¢
Number of feet from building:
7
(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:
License Number:
A
3/84:mj
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER - TOWNSHIP SEC. 3 TN-RW
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IZHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM =2
fl.
;5
t
�r q,
A/0 N.J V.
INDICATE NORTH ARR W
BENCHMARK: Describe the vertical reference point used ��� _&L' a,X
Elevation of vertical reference point: /QFj Proposed slope at site:
SEPTIC TANK: Manufacturer: �y���,��",/-,- xILiquid Capacity: Q r
i IJ
Number of rings used: Tank manhole cover elevation: ,(az ,z-i!
Tank Inlet Elevation: Tank Outlet Elevation: —��m of
Number of feet from nearest Road: Front 10 Side, Rear, O s feet
- From nearest property 1'ne Front,0 Side,O Rear, feet
Number of feet from: well , building.
(Include this information of the above plot plan)( 2 reference dnsions to septic tank)
SEE�RPERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,W& 53707
CONVENTIONAL ❑ALTERNATIVE State Plan P.D.Number:
Nr�, SEA s S 3,T 31N—R17W -` (If assigned)
T o f Sta ton ❑Holding Tank ❑In-Ground Pressure ❑Mound
9nh Streent
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI N A E:
Keith Langfedlt Route 1, New Richmond, WI 54017 C'C�
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:
Cal Powers Jr. I1563 St. Croix 92510
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIOUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV.: WARNING LABEL
LOCKING COVER
O -�� OO °ED: - PROVIDED
S L.>�1YES ❑NO ❑YES AND
BEDDING: VENT DIA.' VENT MATE.: HIGH WA R NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
"EARN: FEET FROM "E AIR Imo:
DYES NO DYES NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNINGLABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ❑NO z DYES ❑NO I ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NU E F PROPERTY WELL BUILDING. V NT TO FRESH
(DIFFERENCE BETWEEN F F O LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO A ST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing ENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH L NO.O DISTR.PIPE SPACING: COVER INSIDE DIA. er PITS LIQUID
BED/TRENCH /-� TRENCHES MAT5 IAL: PIT DEPTH
DIMENSIONS J a
GRAVEL DEPTH FILL DEPTH JDISTR.PIPE JDISTR.PIPE IDISTFI.PIPE MAT AJJJ......��� NO.DIS NUMBER OF JPROPEHIY WELL: BUILDING: V NT TO FRESH
BE LOW PI ABOVE C ER: F E�I ET E V END 0(v ,/) �} PIPE FEET FROM LIN 7 AI�
�// 2 U r�J'f/ / NEAREST--►
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ❑NO
OIL COVER TEXTURE: PERMANENT MARKERS OBSEHVATION WELLS
DYES ❑NO DYES ENO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER: EDGES:
DYES ONO DYES ONO ❑YES El NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.: ELEV.. DIA.: ELEV.. PIPES DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS.
❑YES ❑NO El YES 1:1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
ff DYES ONO YE ❑NO INEAREST-
loi � ❑ � �6
f.
Sketch System on tain in county file for audit.
Reverse Side.
ATU TITLE.
DILHR SBD 6710(R.01/82) t^—, Zoning Administrator
r -
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 bya liceesed• -
pumper whenever necessary,' usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Prcperty owner's name and mailing address. Provide the legal description where the system is to be
installed;
Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment; 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
W. 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
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground fitter-
included the creation of surcharges (fees) for a number of regulated practices which Wisco inti J
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Iea";tf I
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
a
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
1
SANITARY PERMIT APPLICATION COUNTY /�
7 DILHR In accord with ILHR 83.05,Wis.Adm.Code "S/ , U�� X
STAT SANITARY PERMIT##
�S�Q
-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
PROPER Y OWNER PROPERTY LOCATION
c,n4l 2W 1�� '/a '/a, S , N, R (or)
PR PERTY OWNER'S MAILING ADDRESS LOT NUM ER BLOCK UMBER SUBDIVISI NAME
CI Y,STA ZIP CODE PHONE NUMBER Li CITY NEAR ST ROAD,LAKE OR LANDMARK
E3 VILLAGE: f�
11. TYPE OF BUILDING OR USE SERVED: /0• 08'0 - �� - YS--O 0 0
Number of Bedrooms if 1 or 2 Family 17-� OR Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. X 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. XConventional b. ❑Alternative c. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 4 Seepage Bed b. ❑seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
Feet Private El Joint ❑ Public
VI. TANK CAPACITY Site
in ciallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New rxisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank
Lift Pump Tank/Siphon Chamber ❑ ❑
VII. RESPONSIBILITY STATEMENT
1,the undersigned,assume responsibility for installation of theeKvate sewage system shown on the attached plans.
Plumber' Name(Pr'nt): Plu er's Signature• No S mps) MP/MPRS Business Phone Number:
Plum er's Ad ess treet,=e): Name of Designer:
Vlll. SOIL TEST INFORMATION
Certifi d S 'I Tester( T)Name CST##
D
CST' A DRESS treet,Ci ,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved I Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial c� charge Fee
Adverse Determination U�✓ IDS vv
X. COMMENTS/REASONS FOR DISAPPROVAL:
/-l� (J'► tad ,�y �►0 �. �l/��SOh
I .
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house") , then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property �_'1t _3L, Section _. T N - R W
f?wnship
Mailing Address
Subdivision Name P4-
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number 1Gt� as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
1. 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.
I
PROPERTY OWNER CERTIFICATION
I (We) centi.4y that att 6tatement6 on this 4oun cute true to the best 06 my (awt) '1
knowledge; that I (we) am (cute) the owner(a) o4 the ptopenty deacAibed in this
in4o,,unati.on 6onm, by vi tue of a wanAanty deed n corded ina hem Ie(W4 the
County Register of 'Deed6 a6 Document No.
pne6entZy own the pnopoaed a.tte bon the aewage poa ayhtem (on I (we) have
obtained an eaaement, to stun with the above dedc-1 bed pnopenty, bon the
con6tAucti.on o6 aai,d 6y6tem, and the acme has been uCy heconded in the 066ice
of the County R .E6telt o61 Deeds, as Document No. ) .
SIGNATU F ER S;GNATURE OF CO-OWNE$'r APPLICABLE)
DATE SIGNED DATE SIGNED
DOCUMENT NO. II STATE BAR OF WISCONSIN FORM 1-1988 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
• This Deed, made between Dale A. Klawitter and
_Delores I. Klawitter, formerly Rnown as Delores I. rrt c o-��•e
----------------------
Krweger-,--as•
tenants in capmn
-
- /i I.'?o 007
---- ------------------------------------------ ---- ------------ Grantor,
and---Keith_ E._Langf91dt_And_Susan-h.=_.�ngfe).dt Jwsband
and wife as SjV-o--?dip-mt ]._PRPtI'._.........................
-----------------------------------------------------------------------------------------------------------------
•----•---•---- .............................................. ----------•-•- ------- -------------, Grantee, li
Witnesseth, That the said Grantor,,for a valuable consideration..---_
RETURN TO
conveys to Grantee the following described real estate in ...St...0 QiX..............
County, State of Wisconsin:
Part Of the NE4 of the SE4 of Section 3-31-17
described as follows: Lot 4, Certified survey Tax Parcel No- ...................................
Map filed July 24, 1979, in Volume 11311, Certified
Survey Maps, page 832, as Document #358548.
This ----iS--nQ.t......... _ homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And...Dale. ...K1dY174tt�r.. ..I?�1Qx�S.-Z..Klawitter
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
Recorded easements, reservations, and rights of way.
and will warrant and defend the same.
Dated this .......... day of ..._._April
----------------------------------------- 19.--_V.
•------ ------------•-•------- --------------------------- ---..--(SEAL) -- C �
Dale A. Klawitter
•------------•-----------••----(SEAL) 4C._`-��?� ----- c�JG, _CQ.•C �.(g�AL)
* ------------------------------------------------------------ ---•- * ._-De1Qr0S--1--,-Klawitter' -----•--•-- ••----
AUTHENTICATION ACKNOWLEDGMENT
Signature(a) ------------------------------------------------------------ STATE OF WISCONSIN {
•---------------------------- St. Croix as'
------County. ---day day authenticated this ........day of--------------------------- 19------ Personally came 1 before me this ._ e of
............................. 19...B1. the above named
....ale A. Klawitter and
*----•---------------------------- ----•--------------------- ---------
.... .....................el . lawitter---------------------------------•--
TITLE: MEMBER STATE BAR OF WISCONSIN
--------------------------------------------------------------------------------
(If not- ------------------------------•---
authorized by § 706.06, Wis. Stets.) to me known to be the person _§.-------- who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ��-
R>:ALTY WOPID—Dowd Rellanoe
......_. .............................
.....................................................................•-•--•-.... * — 77 ...............
.........................New Ricumnd WI,...................................................... .....
Notary Public _._St_-!CLO].x--------------------County Wis,
(Signatures may be authenticated or acknowledged. Both My Commission is per t f nit ttoa
are not necessary.) g Mk F. HAF VI U plration
_ date: ---MY-$ Not ► i -•)
• ary-Public
State of Wisco --- _ 4
*Names of persons signing in any capacity should be typed or printed below their signatures.
My Commission Expk -
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal lank ca Ise-
H
H
STC - 105 r'
r
a
SEPTIC TANK MAINTENANCE AGREEMENT
C.
St . Croix County
0
y
OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP
PROPERTY LOCATION:,4_ k, �k, Section , Z 3_/N, R Z,7 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 pdt 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 wil•1 be sent approximately 30 days prior to
three year expiration.
tz
0
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth , herein , as set by the Wisconsin Depart- a
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County 'Zoning Office wi hin 30 days
of the three year expiration date .
SIGNED
DATE
St . Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address .
i
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES �.
• DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH f,
P.O. BOX 309
MADISON,WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION:r&'/4,5Y_'/4,Section 3 Ta-N, R 17 (or) W,Township o, Mu. Y
County S�pB—j-� _
Lot No. Block No. c� Subdivision Name ~
Owner's Name:
Mailing Address: AX 9V �� IdG� -s�D.�i
TYPE OF OCCUPANCY: Residence 4—i No.of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW L1___ ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS /Aa—Z9' 75 —PERCOLATION TESTS /0141�7_
SOIL MAP SHEET 15— SOIL TYPE AIV Cf ge
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL
NUM- INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MINIIN
BER
P- � y
P_
KY
SOIL BORING TESTS
TEST TOTAL DEPTH . DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TOO BEDROCK IF OBSERVED)
to 0
72 f
.✓✓J Z /VVy D ZZv 1, r�
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of suits le areas. Indicate number of s uare feet of absorption area
�� �j/� �r
needed for building type and occupancy.�y�rU• .. �� Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
T�A
a
tN
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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) _In Certification No. ZZ 5X
Address--�Z ---�'
Name of installer if kno%�n VF a
CST Signatur
COPY A—LOCAL AUTH RITY _
INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 6395
To be a complete and accurate soil test,your report must irrclrr<:le: •
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
1 MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5, Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
q. Complete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box;
1 1. Sign the form and place your cufrent address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 14") BR - Bedrock
col:} Cobble (3- 10") SS - Sandstone
gr - Gravel (under 3") LS - Limestone
"s - Sand HGW - High Groundwater
cs - Coarse Send Perc - Percolation Rate
reed s Medium Sand W - Well
fs Fine Sand Bidq - Building
Is - Loarny Sand > - Greater Than
sl Sandy Loam < - Less Thar-,
1 - Loam Bn - Brown
sil - Silt Loam Bl Black
si - Silt Gy - Gray
cl - Clay Loam Y Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc Sandy Clay W - wilh
sic - Silty Clay fff - few, fine,faint
X - Clay cc - common, coarse
or Peat mm - Many, medium
m - Muck d - distinct
p - prominent
HWL - High vvater level,
Six general soil textures surface water
for liquid waste disposal BM - Bench Mark
VRP - Vertical Reference Paint
TO THE OWNER:
This soil test report is the first stop in securing a sanitary permit- The county or the Department may request
vcrifr<ation of this soil test in the field prior to permit rssuarce. A complete set c.3f }Mans for the private
sewage system and a permit. applicati:.)n rnrrst be submitted to the appropriate local authority in order to
obtain a permit, The sanitary permit must be obtained and posted prior to the start of any construction.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR RE LATIONS PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RE
(H63.090)&Chapter 145.045)
LOCATION: SECTION: �l TOWNSHIP/MUNICI.P,4ttTY: OT Np.:BLF. O.: SUBDIVISION NAME:
�1 / N/R [ (or f
ICOUNTY: OWNERS BUYER'S NAME: MAILING ADDRESS:
RR
USE DATES OBSERVATIONS MADE
�rI
NO.BEDRMS.: COMMERCIAL DESCRIP PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Z TION:Residence ;r WNew ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system L
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTE -IN-FILL HOLDIING TANK:RECOMMENDED SYSTEM: optional)
S ❑U [,x S ❑U S ❑U EIS AU I EIS YU
If Percolation Tests are NOT require DESIG RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS «
BORING OTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH litl. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B_ oV.5o1 i' G'
B- y
B- % ?
a a
B - `r 7
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. RIOD 1 PE R10 2 PER PER INCH
P-_3
P-
P 8
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 9K-/9 k
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I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified i 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(pri t►: TESTS WERE COMPLETED ON:
A CERTIFICATION NUMBER: PHONE NUMBER(optional):
c—
CS IGNATUR7
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
.2
PAGE OF
`,rVSS SySL20-1
/ Fresh Air Inlets And Observation Pipe
(: --Approvod Vent Cap
6*17 Minimum 12'Above
Fine1 Grade
20-42v Above Pipe _4"Cost Iron
To Final Grade Vent Pipe
1Mrsh Hey Or Synthetic Covering
Min 2*Aggregate
Over Pipe
Olelrlbullon
Pipe '_► o o —Tee
6"A99,*get: o PertorateJ Pipe Bsi:a
Beneath Pipe
o Coupling Terminating Al
Bonom 01 !system
Pro P05cDc�Inal 19nc��t
SOIL FILL
DISTRIBUT101.1 PIPE
APPROVED StfNTIIETIG COVER
li IIATERUA1- OR 9" OF STRAW
Q"OFgG6REGAIE -fir OR AARSN HA'-J
�/� (e,OF 12-212 AGGRE.C+ATE �"B %• �%
DI57'RlBUT10AI PIPE TO BE AT LEAST 112112 INCHES BELOW 09110 i IAL GRADE
AAIU AT LEASTZO INCHES BUT KIO MORE THAI) 42- IUL14ES BELOW FINAL GRADE
MAXIMUM ®EPTH OF EMAVATI60 FROM oKI&V AL 6KADF- WILL BE 5"y INCHES
PUNIMUM Mf" of EXCAVATE®N FR0M'01�14INAL BRAD€ WILL BE — INCHES
SIGUED:
LIC EW SE UUMBE R:
' DATE
110
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SURVEYOR'S RECORD
UNPLATTED. LANDS, W m
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S 000-30'-21" E z �
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;NV,. i 9pO 300.30' ,��Dni� p
0 CID
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O H m i (>Z w ��' 6\ v cni i W
Zl�
'Tim O+ w w p N N 1 0
vl D a) O N }
lo m
pit
m S 000- 33'-14" E cwn_
W
329.13'
O'CbNk E O 299.37' f�
lPf� Of ps+ aLt i wa O NI 1 :C
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w O l I O n-1
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= r - z m w owll W '
l CD N _
Z m -4 co v m z 1 S 000-36'-07" E ��`` .11 a) I W m m
U) = r v Z 1 298.44 �� �� '
z cWn m O w CD �'� 329.21' /mom ---' p N
C z m —_ I I �a? I
� z
m r � O w 329.23 W
D Z - p
298.24 m
S 000-36'-07 ' E / TcoA f D I
C
m -1 m i I ral O -
D ;o cal I w W
cn w I m C
° Z w ^' w w I W -i (mil
W �,, p of
m
O` > N N I W
{ D /�
APPROVED N Z
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Z D m W N I ..
O z N OD ( .D ;o
JUL 18 1979 :N :o
— D
W rn S 00 39'-02" E cn � � � .N �
3 -- 329.31' m -�
t0 ST. CROIX COUNTY 2 9 7.32' � w�
COMPREHENSIVE PARKS PLAMNINO O
AND ZONING COMMI1iEE teal
N
O i
W N r °' w w
w w 0 N — —
p (j) N N I I
APPROVAL OF Tt{S MWGR SU iDViSION'n I O `1 p
P f"n� -4,wO-�4
1 o D N a' N
DOES NOT MEAN APPROVAL FOR D p m STE ,BUILDING SITE OR SEPTIC SY m
RER TO H62.20, w
Z-n 296.39' \
m ' �
329.39 -A I I l I
1
/
m
N 000- 41'- 54 W
UNPLATTED
LANDS v O
N ;o O z
/r l I I I
I
r t
`
m
2 m ;D w
BEARINGS ARE REFERENCED o �+
z t
TO THE EAST LINE OF v
VOL. 3 PAGE 632 SEC. 3 , T 31 N R 17 W �.�.
CERTIFIED SURVEY PIAPS (ASSUMED TO BE N 00-4l'-54"W)
ST. CRUIX CUUNTYt WI. <<c .!r:e J 'age c32
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit _
State SepticLK"
NAME Y0!2,_-*0y,;tlgj:fteTowns h ip vd&lw_� St. CAoix County
Location -L—section .3 Lot # Sub'd,i,vision _
SEPTIC TANK
Size gatto nb Numb en o6 co mpaAtment,6
Distance 6Aom: Wett Building 1.2% 6tope _
HighwateA
PUMPING CHAMBER
Size gattona___ .,Pump Manu,6actuneA Modet Numbers
HOLDING TANK
Size gatton.6 Numbers o6 CompaAzment6 _
Pumper A.taAm System
Distance 6nam: Wett Building 12% stope_
HighwaxeA
ABSORPTION SITE
Bed Trench
Distance 6icom: Wett Building 1.2% .6.tope
Highwatext
ABSORPTION SITE DIMENSIONS
Width o6 trench bt Requited area
Length o6 each tine 6t Depth o6 rock below .tile
Numbers o6 ti-nes Depth o6 rock oven ti e
Totat .Eength ob tines bt Depth o6 tite below grade in
z
Distance between tines 6t Stope of trench in. pen 100 kt �
rn
Totat abaonption area 6t Type ob CoveA: Paper on 6ttaw
PIT DIMENSIONS
NumbeA o6 pits GAavet around pit.6 yeas no
i
Outside diameteA 6z Depth below inter T_ ��.t
Totat abb onption area 6t
Area AequiAed 6t
INSPECTED By TITLE
APPROVED DATE 19t
REJECTED DATE 19
REASON FOR REJECTION
r,.
REPORT ON INSPECTION OF SANITARY PERMIT # 13,5 7
1 Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection
ea—me. re s, o. o ns a Ing Plumber
Time of Inspection
-
(3)INSTALLATION CONSIS S OF: ❑ Septic Tank ❑ Seepage Trench ❑Dosing Chamber
❑Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fi11 System
ermanen reference Point) escri e:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well :
M DOSING TANK: Manufacturer: # of gallons :
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑YES [:]No Wired? ❑YES ❑NO
8 HOLDING TANK: Manufacturer of gallons ;
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES [] NO; ft from residence;
ft from well ; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑NO; Wired? []YES ❑NO;
Locking device on cover? []YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well ; ,ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length tile depth;
lineal feet tile; ft to residence; ft to well ; ft to lot or
line; ft to ordinary high water mark f lake or stream; ft to edge
property Y 9 9
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE-TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well ; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? []YES ❑ NO
(13) Has system been installed in floodway? [:]YES ❑NO Floodplain? []YES ❑ NO
DILHR-SBD-6095 N.0 /8
Signature of Inspector:
PLB 6 State and County State Permit # ��
Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: % A4 %, Section , T N, R 17 V (or) A Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family _X Duplex No. of Bedrooms _ —No. of Persons_
D. SEPTIC TANK CAPACITY /060 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other(Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft.
New Replacement Alternate (Specify)
Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (toy/)_No.of Trenches
Seepage Bed:--X Length $1 Width 42'Depth.i� t Tile depth (top)3r No.of Lines��
Seepage Pit: Inside dia r Liquid Depth No.of Seepage Pits
Percent slope of land <m�ett Distance from critical slope —'
WATER SUPPLY: Private X Joint❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that 1 have sized the effluent disposal system from .the EH-115 prepared
by the Cer ied Soil TeRtMAC
NAME A41JA./ , C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# ^mil _Phone
Plumber's Address in.�nAJa /q T
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY p L
Date of Application � >7— — G Fees Paid: State 2S- L� Co my � Date —O —O O
Permit Issued/Rejected (date) '7 Issuing Agent Nam
Inspection Yes.)<' No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised ti3ate 7/1/78
EN 115 Rev.9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309,MADISON,WISCONSIN 53701
LOCATION:'/4,S/= '/o,Section ,T N,R12$ (or)W,Township or Municipality Sf r�
Lot No. , Block No. County
Subdivision Name
Owner's/Buyers Name: r
Mailing Address: 3 1 «�
TYPE OF OCCUPANCY: Residence_A/ No.of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS ;Z9 . PERCOLATION TESTS -t'/1- 2 9
SOIL MAP SHEET S NAME OF SOIL MAP UNIT .JAWf'n
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P— s % '/
Qa-
P___9 O / , f, 0
P— �� - `
P—
P—
P—
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,
TEXTURE,MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B-
B— 7 C
B-
B— 916
B— 51K, IV _ q - 9 _ q
B— ? — —
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the ion and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type d occupancy g�s � Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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I,the undersigend,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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) Certification No. .S• ,-jj
Address
.Name of installer if known
Copy A—Local Authority CST Signature