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HomeMy WebLinkAbout040-1065-90-150 § o > 0 0 ( § � ƒ � � f � \ n \ c ƒ 2 ] k � § § a 2 E � § z 2 k k k c = u z CD \ § Cl) \ "IVA $ / ) c _ g \ ) z !E .. k � 2 � c � ~ E c ~ . 0 ƒ \ / A § a � g � } k § D - ■ ■ § 4 § \ \ k k ° -� t § a a n is U) \ § k \ k k C) � ) § d « = E / » @ I g 0 2 ± / _ I � = E coif @ ~ \ § \ \ � { § % $ � a » ' a # � k r - 2 f ) / ) � • $ ) � k - k \ / \ k o z / z \ � © k L , _ . . . a o 0 a 0 2 0 PUMP CHAMBER v` Manufacturer: Liquid Capacity: i 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, OSide, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM I / Bed: Trench: 4 Width: -31( Length: 3 . Number of Lines:­Z Area Built:s� Fill depth to top of pipe: . y y;2 Number of feet from nearest property line: Front, O Side, e 0 Side, Vt . 1--3 Number of feet from well: or�-e.( S� y Number of feet from building: 9 ^ (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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: A a'& g Plumber on job: License Number: 3/84:mj t Form - S T C - 104 • AS BUILT SANITARY SYSTEM REPORT OWNER r � TOWNSHIP =0 SEC. T _N-R� ADDRESS kfir CROIX COUNTY, WISCONSIN SUBDIVISION / _ ��c LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 F4 5 r - - — - - I � � I E , 5INDICATE NORTH ARROW BEN Describe t he ve tical refere ce point used Elevation of vertical reference point: 000-tbroposed slope at site: 2 _ 1 1,3 j.as SEPTIC TANK: Manufacturer: ct9 he.,w,,Am, Liquid Capacity: 1,0 0,0 / Number of rings used: Tank manhole cover elevation: Tank Inlet evationc Tank Outlet Elevation: Numbeksof et from nearest Road: Front 10 Side 0 Rear, ;2 2 eet From nearest property line Front 10 Side,O Rear, 9 feet Number of feet from: well O'trU1 �0�, building: ,2 (Include this information of the above plot plan)( 2 reference dimensions to septic t SEE REVERSE SIDE ..A DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BMY 7969 BUREAU OF PLUMBING 1,MACWSON,Wis 53707 NWk� t'4k,S16,T28N—R19W ❑CONVENTIONAL El ALTERNATIVE State Plan l.D.Numb er: III assigned) Town of Troy ❑Holding Tank El In-Ground Pressure El Mound 86-03649 TownsValley Road System In—fill NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA E: Ken Schoeetle Route 3 Towns Valley Road, River Falls, I 54022 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: Henry Nechville 3258 St. Croix 99022 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY TANK INLET ELEV.: TANK OUTLET ELEV.: WR",NG LABEL LOCKING COVER A P DED: PROVI ED: 14) JyJ% i 11 { '�x /V ✓a YES ❑NO YES ❑NO BEDDING: V I .: IVENT11 TLL HIGH WATER NUMBER OF RO/A�D: P WELL: BUILDING: VENT TO FRESH ALARM. FEEL'FRDM '1 J L / LAIR INLET. ❑YES NO E1 YES 1:1 NO NEAREST �J/l v tf '/ DOSING C AMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMPISIPHON MANUFACTURER. WARNING LABEL INE CKING COVER PROVIDED: OVIDED: ❑YES ❑NO OYES ❑ -]YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL- DING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: 1 WIDTH LENGTH-. NO.OF DISTR.PIPE PING. COVER INSIDE DIA.. *PITS. LIQUID BEDfTRENCH S � TREN�I-IES /r l MAj�RIAL: #yiT DEPTH: DIMENSIONS dl" /lG e`L GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: N-_ O.DIs R NUMBER,OF PROPERTY WEL B L ING: VENT TO FRESH BELOW PIPE/S- ABOVE COVER. ELEV.INLET ELEV N �, PIPES LINE- AIR IN LET: �0 (� � t `�— NEARESr— 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 1:1 NO SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS. ❑YES 1:1 NO ❑YES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED. CENTER EDGES: ❑YES ❑NO ❑YES 1-1 NO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BEfl1TR (iII TRENCHES:WIDTH LENGTH LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER FINCH, DI� l1ISIONS ' ' i.MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.. ELEV.. DIA.. ELEV.: PIPES: DIA.: LI=VATION•AID' plIS7RI�TION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INI~EkR1WATI(IN PLANS ❑YES 0 N DYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: INIJaIBF.R©I,'" PROPE RTV WELL: BUILDING: LINE: ❑ El NO DYES ❑NO NEAREST All iqot Sketch System on file for audit. Reverse Side. TITLE: SIGNA DILHR SBD 6710(R.01/82) Zoning Administrator i INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION ' TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed .pumper whenever necessary, usually every 2 to 3 years; 6. if you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: Property owner's name and mailing address. Provide the legal description where the system is to be installed; 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; 1!1. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check ail 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; VIE. 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; Vill. 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 8Y2 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. - --------------------------------------- ---- s GROUNDWATER SURCHARGE I I On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more corrfmon':y 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*at,er included the creation of surcharges (fees) for a number of regulated practices which Wiscor in`s a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried �Tea5ft1B' is used in your building is returned to the groundwater through your soil absorption a system or the disposal site used by your holding tank pumper. a The cror es :ol!ected through these surcharges are credited to the groundwater fund adminis- ±;red by "he Department of Natural Rc sources. These funds are used for monitoring ground- -il.'ater, groundwater contamination investigations and establishment of standards Grcundwate!-, it's worth protecting. SBD-6398(R.03/86) DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code ST: c e°Qi'X,_ STATE ANITARY PERMIT# '-Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. — 6.3 –See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ®NO PROPERTY OWNER PROPERTY LOCATION eEN ScAo v TLS A'Al % 5& %, S T 2-e, N, R IF E (or W PROPERT OWNER'S MAILING ADDRESS LOT W MBER BLOCK NUMBER SUBDIVISION NAME � . , -r4wws vit//� Pll e OF 41 s �Y,S E��/� �i Z�y��Z PHONE NUMBER Y NEAREST ROAD, LIC I!�RLAGE: 'T/�Q TArcifJS �71 "Q' II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a.kSZstern w b.El Replacement c. ❑ Replacement of d.❑ Reconnection of e.El Repair of an System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1 a. ❑Conventional b. ❑Alternative c. ❑ Experimental 2. a. System- b. ❑ Holding c.❑ Pit Privy d. 1:1 Vault Privy e. El Mound f. El IGP )(1111n-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b.Z Seepage Trench c. ❑Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVt4TION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): /D/ /2 Z 1195" Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App 9 structed Tanks Tanks Septic Tank or Holding Tank an �E oNC El ber ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(I o t raps) *{P/MPRSW N Business Phone Number: HEVR( tJccl nille- �� .12- S' 71S 7Y —331- PI s mber' Address(Street,City,State,Z' Code): Name of Designer: fit•/ • G fo a firs S. SY6i VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name NO _SI fl CST# RT.j 0,NE4L R6•,Id(1OEON,WIS.54016 2'y'?2 CST's ADDRESS(Street,City,State,Zip Code) LOR MASTER PLUMBER N0.3307 M.P.R.S. Phone Number- "S. b �j IGNER UC.N0.00663 7 -7 300(;—Q l Q IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee Groundwater ate ilssui Agent Signature(No Stamps) ®Approved ❑ rcharge Fee Owner Given Initial ` Ck� r✓� 1y_a >' C�7 Adverse Determination / �(../ / X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber V. 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 � �,,�t Location of Property 1 .-_,-_-_5rA, Section , T.,ZZ N-R- W TownshipJ�.a.�. AOW �..�- Mailing Address 3 , Address of Site- Subdivision Name Lot Number Previous Owner, of Property �y� f^ CL 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 y No Volume �Sl�.''` and Page Number ---�-- as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTy OWNER CERTIFICATION 1 (We) eeAti.jy that att .6tatement6 on th.f,6 Sonm ane tAue to the best o6 my (oun) knowledge; that 1 (we) qP- (ane) the owner(.6) o6 the pnopexty de s c i.bed in thiA in6 matLon Sonm, by vi tue o6 a waAAanty deed neconded in the 046ice os the County Regi6ten o6 Deed6a6 Document No. O ; and that i (We) pnesentty own the pnopoeed .6 to San the .selvage diAposat system (on I (we) have obtained an ea6ement, to nun with the above de.6cAi.bed pnopenty, Son the eonbtnucti.on o6 .said ey6tem, and the same ha6 been duty neconded in the 046ice o6 the County Reg.i.6ten o6 Deeds, a6 Document No. ► . r".0Z zae� SIn ATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED x ' ; DOCUMENT NO. WARRANTY DEED STATE OF WISCONSIN—FORM t THIS SPACE RESERVED FOR RECORDING DATA 298201 'I'lliS 1NU@:N'I'URE, h1ncic this. _.18t... . (lay of.........October ..................... A. 1)., to 69 belwcen. Franklin.E..Harwell .and..Sheryl.t. ST. Croix co" wi�s, i� .Harwell,..his .wife... _ _._............._................................................................... Recd for Record ti;ic-,_13th _. .. ........................_.. ..............,........................ day of__QF9ke_r x.0.1969 .. _._ .......................................................... ........... ............part..ies ..of the first part and at- '8r��'---/ -�, Kenneth L..Schoettle.and..Betty .E.. Schoe.ttle,...husband........... s I and wife as ajoint..tenants. ......... ..... .. ................................... R ,Is er f)n�{Ic .............. part ies 4f the morond part, RETURN TO W i t n e s s e t h, •fhel the said part ies of the first part, for and inconsideration_ +,f the sum of One Dollar. ($1.00) and other good and..valuable.......... consideration----_------------------ ----- __ .-r-- ---------------------t„ them _._in hand paid by the said part...tole of the second part, the receipt whereof is hereby confe,;o l.uul urh no•.c led{ed,ha_ve t;icua,f ranud,bargained,cold,remised,released,aliened,conveyed and confirmed,and by these presents do );t+'+',{;rant,bar>'.nn,sell,renu,o,rclea,o,alicu,convey and confirm unto the said p;tr4.F:.Q....uf the second partt/hCtXherrs and assigns fmv%et, tlrr following descrihvd real c,t.!te ,itu:atvd in the County if....Ste _Croix..............and State of Wisconsin, to-wit: All that part of the West Half (W�) of the Southwest Quarter (SW4) of Section 16, Township 28, Range 19, lying Northeasterly of the town road, EXCEPT that part deeded to Terry L. Hines and wife in Vol. "435", page 410 and EXCEPT part deeded to Kenneth L. Schoettle and wife in Vol. 11436", page 72, Office of the Register of Deeds, St. Croix County, Wisconsin. (If' Nl:('LSSARY, CONTINUE DESCRIPTION ON REVI--RSI; SIDE) Together a+:Ut all.onl ,1! '111.4 the 1wo-,diianu:nts and appurtenances thereunto belonging or in any wise ap{xrtaining;and all the estate right,60,i;a,m,!,cl.!im,:r d—.ind ,+!,:u ,,, ei .d the said part ieBof the first part,either in law or equity,either in possession or expectancy !'' Ow.ifiuw f"!rv;r;iir t.f,r,ini v-♦.ii!,I Ow;r he•reditanients and appartenrances, To [Lace:uad To 114041 Ow , 6.1 la.n:i .shove de,+ribcd with the h,•nxlitanient.s and appurtenances, unto the said part ie.A.of the their \n41thesaid Franklin . Harwell and Sheryl.C. Harwell,_hie wife.. .......... .. ....._..............-..._:......._... their hrir., c>.ccutnrs and adwini,tt:+tor,, do.:. .. covenant, grant, bar{!,tin, and agree to and a.itii it -n.! ;,;rr ies,.f ill, -.,—il'! f.+rt, their_ heirs and :rs,it:ns, that-at th„ time of the ensealing and delivery of these presents they are ;! •,"iie,l if I, p:,mi—, :rh„(c do°,ribed, as .,f ,t good, sure, perfect, absolute and it)it! I ate of inheritance in r!r, lo, of fee ,unpb, .nil th.it the -.ou.•an• fr,•+•and dear front,ill incnmbranre-i avhatever _..... ._ ... ,m) ch,r its, d— .• I u(:.iincd prrnii••.-•, in ill,-gijiet and pea+e.tble posse,>ion 4f the said part ieS.r,f the second p.trt,..theliWrs and a.,ign., (I �.;.�.•� �, n l .uu1 +c.•r. p?­n or p,r-on, Lawfullc cl timing the µhuh•or anv part thctrof,.Ih @yr.._.will forever uu WARRANT DlL :\C In \\It"ess Whereof, the 'aid �test ies�d the Ent {art ha... e...hereunto set their h: 1 8 l 8 tfy1st . i fa+" October A. 1)_ 111 69. . Sl(;Ni:l> AND SEAI,E1) IN 11RESENCE ON _(S[::1f.) j Franklin E. Harwell . .............. ... Nalscy M. Bar�k�la ,) Shezyl...C.....Harwell........ ......... .• �%�/(��'-/r✓<<., C1'� �<��Q.�-�,�,_ (SEAL) ........................... ..........__.,......._..._.... Barbara..A....Prissel ............ (SETAE.) ..............................I........................................ STATE OF WISCONSIN, Pierce }SS. Personally came before me, this ... .... _....l$.t .................clay of.............OCtObeS.....................................................A. D., 19... 9... the above named......Franklin..E....Harwell and...Sheryl..C.....Hans+ell....................••.............................•............................................. �I _ ....._... .. _._....... .... ....................... .... .....................................................................-.............................................. to me known to be the person...a...who executed tide(, Itfg tnatruinegt and acknowledged the same. v e ` ..• t NO1AilY 1 eX..MLU A$x .l ..................................... ORAL. This instrument drafted by t Notary Public._.Fil eP'X'ce.......................................County,•Wis. Nsnc3f AttorT7le . •a. �... Y....:......::....:.......... .: -�. My Commission(> (le).........}e P giver Falls, Wisconsin smesne�tti (Ri ctton 69.61(1)of the WUanefn 8atata provides that au ne umeAa to be ad shall!have nl•taly prinled or tspewrttpa thereon the"man of the yAaton,6wntea,wltneaa and notary). WARRANTY DEED—STATE OF WISCONSIN, FORM too 456 FACE N.C.MILLER CO.,Irn1I16OCt N z tA H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT c St . Croix County x W a OWNER/BUYER ,. . ➢� =� -�Q �'" ROUTS/BOX NUMBER & ,,,_„� „-� �1� /Ldp Fire Number .CITY/STATE „ g6 ZIP ,5� yo �. PROPERTY LOCATION:�k, Section /49� , T --,'A,? N , R__Z2 Town of /�`f , 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 will be sent approximately 30 days prior to three year expiration. H 0 E 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- o 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 St . Croix County Zoning Office P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 lSign, date and return to above address. INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 ` To be a complete and accurate soil test,your report must include: ' r 10 Complete legal description; 7 The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; a. 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. Mal<e sure your benchnia,k and vertical elevation reference point are clearly shown,and are permanent, S. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. ! °rt: information (such as flood plain,elevation)does riot apply, place N.A. in the appropriate box; 11, Sign the for and plane your current address and your certification number; 13. 'take legible copies and distribute as retiuired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Texts€res Other Symbols st Storms (aver 10„) BR - Bedrock (,of) - Cobble 13 10") SS Sandstone gr - Gravel (under 3") LS - Limestone 's Saild HGVV High Groundwater �,s - Coarse`1aild Parr; Percolation Rate n,ed s Median; Sand psi _ ki"',e€I 'I - Fine Sand Bldg Budding Is - Lcaamy Sand 11 -- Greater Than "sl Sandy i_oarn -- Less Than "I - Loam Bn - Bro,,Am �sr, Srlt Loam BI Black Si - Silt Gy - Gray �cl - Clay Loan, y Yellow scl - Sandy Clay Loans R - Red sic,I - Silty Clay Loam mot - !bottles sc Sandy Clay w/ - with sic - Silty Clay f f -- few, fine,faint C - Clay cc - common coarse pi Peat rnrn - Many, finediurra ni NIucic d - distinct p - prominent HWL - High water level, Six general ;oil textures surface water for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: s srIj test report is the first step In socuring a sanitary perrrast. The county or the Department may MuUest < 4icat=on of this soil test iii the field prior to perrrait issuanco. A complete set of plans fo, the private s �cpr= sus •s,ra <l-ad a rwrn it amlication must her submitted to Hie apapiopriate local atith0lity in carder to .r p nrI4 hk.,Y�r°=.rfy `.i?Clll It 1-nosL he c7bl ine,rl and posted p)"i"lm to. the start Of any constrLwtVtn. FTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS RY, DIVISION R P.O. BOX 7969 LABOR AND RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707 (H63.090)& Chapter 145.045) LOCATION: SECT TOWNSHIP/Mb ttCtrACTTY: OT NO.:BLK.NO.: SUBDIVISION NAME: E,i, 1/a, 1/ %� /L9 N/R/9 E I. T.Poy- E4tsr 'Avt COUNTY: OWNER'S`Bt R` NAME: MAILING ADDRESS: sr eivzx >�//.r Cvis. sya Z USE DATES OBSERVATIONS MADE NO.B RMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS:IPERCOLATION TESTS: Residence AJ _ )<New [--]Replace I E zl lr/?6 TPuE 9 RATING:S=Site suitable for system U=Site unsuitable for system C.5 Ce2D_ r0 :Z)2— ��ETEF! Q���f/� _ .� CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LLHOLDING TANK:RECOMMENDED SYSTEM: IF EI S Eu DS 7U ❑S Zu S DU D S ®U SYsr�•N IA, If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the :Z7-- under s.H63.09(5)(b),indicate: CLASS Floodplain,indicate Floodplain elevation- -2'4o3' SrI .TS CUT Of I= PROFILE DESCRIPTIONS -rAkr j iN C'u7-aff, ?4"060 f/'T BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) ' �UDD/eD /vET " G'' � �,� %f v 74IV C 5 GAP. 7 ' 3,v BAi 10 0-F S .B- / Z./3 So 7 o i / cs r�,�T 83• T2Av cis o • c p. /s. �J mot' ��voieD �. ,l 167 'T,qv Cs v�' ?v. S/ S3' 9'4w B-Z /'v /D Z.2 CvET dr J• ,6 / 3;.rA-/T%f1EO y „ i1ck AoZe4sy77v 1A ye'*4, o'� " �u/�ID✓ED wET " d,5'ji9n/ c5 � .d8' 1?v.S1 /,o'T',v c-S 3 6 e � 2.V2 B-3 4. 0 le,2,12-, #r &o" S.O (D BN. &Eef IM., 5/ 3,0' T cs 33 ' BN ,v C's .G 7 B- B� • � S pvopf&p w:r / 2.5 ? s 25' ' Ya S1, •Z r,f� 7 0 4T 7a 1 B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- / 40" 2— / ' 2 Z P- P- L P P- /'0 ' 1 ?/ 'lee 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 E W (---f—�—v --+ t—•---F_v/? _ -t- - - T { � / / I "I`t9 S©I Lf f _ fill _ - - j i �r�s�✓u I t� CS ST T d �� ST.ei{GT�UL� i}ti1f> D/� . Flo ' u; r lt, _ , ` I,the undersigned, hereby certify that the soil tests reported on this for J(igr 'lad by me-i,�c rd with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the re co o t1ibe y y knowledge and belief. NAME (print): HOMESITE SfPTIG PLUMBING CO. STS WERE COMPLETEQD O�y H USON.WIS.54016 I��1'/ �/D �! ADDRESS: ROBERT ULBRIGHT /` R�TI C�ONNUMBER: PHO E NUMB (optional): WIS.MASTER PLUMBER LIC,NO. 3307 M.P.R.& F YY M ~i \ CST IGNATUR G l iT DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.02/82) —OVER — 7,V REPORT ON SOIL SORIN&S ; PERCOLATIoN TESTS 115 PLo ' •� N OT ECT r• D. �Eg/ 5c 771,e- PROTECT_v . A p , DATE . 9 o0j -5 YY7e.4 BOB uvRl C" X57 SS-at yOz H MESITE SEPTIC PLUMBING CO. IT 80'NEIL RD.,NUOSON,VAS 5016 RMERT IILBRICNT MR.MMSTER PLUM10 UC.N0.330)MUM WA INSAW i OSIGNER UC.Na®0663 PROPOSED t10VSE mu-sr Lie 2� Fr. opt Mo�tE FiQOM AL,L TEfT ,loPEAS, poo posE o WELL M osr LIE SO FT. �� IyD�PF FiPo." 41.4 TEST ^005. • = BAt,e*w- PiTS © wri 1. NONE 'C#6T$ X s leEQG loC.#rl&wf )( s #,4No A011"" At 54,& lEL BES • • !lo,eit . BM P e'e —iem- of pek . SET Iiv Ad. P#e4. 4s S. w,v LE GE N D 161"Arow of got. A.M. PT /O0 • Q Fr- c wsT Li�E P�OPtier/ ,2 C 90 - SiT� • V i 410 A�SajeEXB�E" StoP�s 30 r ! U , xP 1 L y8' tlw,ES%rE � • X `__ to 3 i i1 R L K5 foo B to CENT 35 ICA 3S� � wV t � k Y rill p4or R4,IN PZAIV 1114Ekil k,,'A/ 56604-7W A00 J?567- i 3 T a S I( S�v % o -e t, R i g UD S�pT� (),F a) me,4 //Z),q e, 5 evAowy�� /Olenocz;�; doy 12e y � � M�.vvf�x o pooEx c,9�or9�:T ioQo P . y c po' r i✓dR�� Z07 LivE) �o our of Al FPovA VL, 50 • �_ fi—Two ,�-Xsa o - E ►° 33 r2EP�.acE.r►�r � � j $s 0 ----� 0 99 I wE /25 - � y,S- ' woo Per. 4or pr� SGo �S f CiPDs`S 30 OA')055 SCC r1aw Zee r4 14' o�= A 5 y 1;7 CM L- �,pE,v c Ht's 7T6 /3E7-- �,E�ill ��EUiovs N4jU,P,9 L E-1E M Tio.v 105 -/o /406 Fresh Air Inlets And Observation Pipe �-• Approved Vent Cap Po,00SED ;�„s ,ED Minimum 12" Above G*AOe- Final Grade I(� �/� ► fr f R6POSE� Aw v-Z'r I of 7'0 l0vb"e fill �� 4�� Cast Iron�� P /$ Above Pipe — �� '� To Final Grade Vent Pipe Fr SyLe ring �XiST�.u(� �"/O � , I 1 Migate 9i�,lDE O Distribution Tee Pipe 0 0 (o Aggregate 0 Perforated Pipe Below Beneath Pipe o Coupling Terminating At Bottom Of System 5ysf�M T ioo 3� 7 is i Sb iL i ��U'Of�Y�t7 SET Safety b Buildings Division =(�) DILHR ON—SITE INVESTIGATION FOR CONVENTIONAL SYSTEM IN-FILL &+react Of Plumbing P.O. BOX 7969 MADISON, WI 53707 Owners Name:�CN ScAo ETTLE Evr/1Pfr1Alev y SW i s�(� TLP I���1 w Usage: /QV New Building O Replacement System Public Residential Nom Bedrooms 12s) 1 8 Square Feet , Depth In Inches to Eeon aced To Ov rcome Depth Tod Fill Placed 20 Feet Around Area Soil Absorption Limiting Factor From y(� Proposed For•Inittal Yea No stem Required: 10riginal Grade / 4 water Bedrock And Replacement Area O O te Fill JUNE soil and Monsandy Monitoring laced: {� ��/_ Soil Removed Prior to © Yes O No ior To Yea O No Required: O Yes©No (D Of Fill: lll...111JJJ exture Of Fill Indicate Texture Does Fill Conform o aterial Sameoil; 0 Yes O No Of Fill Material: p C s Sectiodmin63Code6) O Yes O No Explain Any Problems: Complete The Following: Bench Mark Elevation As Established On 115 /��•O Finished Grade Elevation /� ' ' O FIAIISHCD /p y0 VRADE—� — '. '. 1 _y.' .;;;.• A' B ;d: Depth To Limiting Factor: ORIGIIIAI .. C �. .. t .. .. D : GEL�V \ \\��� \�� eWct6 WALE GRADE Depth Of Fill Material: ��'� �� LESS Toeu#L AMO HOR WO1 B/�"'ToP coin S \\O�i��OFMOrrLiNaDepth of th Topsoil and Nonsandy Soil C Than 12" of 4ottlLn g* ` /� Fini34ed Depth To Limiting Factor: RA 11JTEFCE OF /UY D [f LIMITW& FACTOR ULY. / Total Length Of Area Filled: _ 9Q /NCLU CT -- Total Width Of Area Filled: a C / F Y7 41 A, Dimension From Proposed Edge Of AQ = v \\ MA1(IMUM 3: 1 Trench To Edge Of Fill (min. 201) 4O V H \ SLOPE –ALL sloes— G 2- 0 Dimension From Proposed Edge Of I TT �� i C-� Trench To Edge Of Fill (min.. 201) 4/ C !.v ']� H Z U Separation of Trenches (min. 6') Signature of�u Representative/On-Site Waste Specialist DILHR SBD-6196 (8.02/83) Name: —Date: ON—SITE INVESTIGATION FOR Safety 6 Buildings Division � D I L H R Bureau Of Plumbing CONVENTIONAL SYSTEM IN—FILL P.O. BOX 7969 •�,,�- MADISON, WI 53707 Owners Name: Legal Descriptions: / r l^/6 / Z f) L)/fi Building © New Building O Replacement System O Public © Residentlal 7No. Bedrooms Usage: Square Feet Depth In Inches to ,. E aced To Ov rcome Depth To• Fill Placed 20 Feet Around Area Ler orption y�c, Llaiting Factor From 1 water Bedrock Proposed Replacement O Yea O No e ulred: ✓ 10riginal Grade And Replacement Area l UN[ soil and Honsandy (; Monitoring 3�{ r Soil Rmoved Prior to O Yes No ior To I X I Yea O No Required: OYes©No Of Fill: l�J Of Fill Ind Cate Texture Doea FS Conform o O O Same Yea O No Of Fill Material: [ C Section H 63.10(6) Yea No ln Soil Wis. Admin. Code: Explain Any Problems: Complete The Following: � y ' Bench Mark Elevation As Established On 115 /���� /�Finished Grade Elevation O FlUISHED /oyo &RADE i, :. l y"°.;;:. A';. 9 ;a: Depth To Limiting Factor: ORIGINA1 — - — C . .. .. D A G \��\\�� �571 N(r �O Z Depth Of Fill Material: L G RA OE q .°\\\�\ �\:\ \� LESS TeF3eIL AND NsNS"Of B/,0 ToP <OVfie /OS. S .��\,�/\��;•. ��•,, 5.IL WITH LESSTIIAN 1A00 _ OFMOTrwoic ` DWithLessoThan 12"off Moattlingoil C jq!/9 oDX 3 T T --r —t—J— _I_ I I =r—L �TL T Finished Depth To Limiting Factor: IWTERFACE OF 9�.12— L,� rr- LIMITING FACTOR ULY. D Total Length Of Area Filled: !U:'�!t'( E G ��/ c _ -- � :/ Total Width Of Area Fi=:ed: 4f` A. � Dimension From Proposed Edge Of E MAY.IMUM 3: 1 Trench To Edge Of Fill (nin. 201) �t- 4 H \ SLOPE —ALL SIDLS— G 2- 0 , j '- IrP QJ \ V Dimension From Proposed Edge Of \� ,. Trench To Edge Of Fill (min.. 201) "'---— F Separation of Trenchns (min. 6') Signature of County Representative/On—Site Waste Specialist DILHR SBD-6196 (8.02/83) W.- nnta- T '7biLHFi PLAN APPROVAL Safety and Buildings Division Bureau of Plumbing P.O Box 7%9 r ❑ General Plumbing-Plans Madison,Wl 53707 Private Sewage Plans Telephone: (608)266-3815 i A �. -C I F Project Name Project Location - Street No. or Legal Description K L 4 Z T ounty El City ❑ Village own of: — - o C The plumbing plans and specifications for this project ve been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145,Wisconsin Statutes and the Wisconsin Administrative Code.The plans are stamped"conditionally approved".This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected.All permits required by the city,village,township or county shall be obtained prior to construction.The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site.The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g This approval will expire two years from the date approved below.If construction has not commenced before the expiration date, new plan a must be obtained. FOR PRIVATE SEWAGE PLAN (1) (2) (3a) (3b) (4a) (4b) (6) (7) This approval will expire two years the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only.All other system reviews must be submitted to the Bureau of Buildings and Structures. Comments: By: i James Sargent Bureau Director If Questions Plans Approved By: Date A proved: Contact cc: Priva ew ge Consultant ❑ Plumbing Consultant ❑ Environmental Health County ❑ Local PI ❑ Facilities Need Analysis Section ❑ W-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099(R.01/85) ❑ Owner ❑ Other i PROJECT I_XD X SHEET g6 - 03649 T ! OWNER: ADDRESS: ��• .3 /BIUNS //���� /�� . �""%r'l��' ,�,��,�.5 G�i��S. ,S U0.2_Z.__ y SITE LOCATION: sw I s c• T-) w / s � y y y � PROJECT DESCRIPTION: 'of w l I-44- u/hs r - lvws Ai b y , ��� �� z Oti L/ u d2. f rAj si S0115 � y IN f?l f i. PAGE 1 . PLOT PLAN VIEWS PAGE 2 . � `tT o .& SYST r,M P7i!12I err. r a-mrm.A t_ r n vnTTrt PAG-7 3• ----- — - - 1 PAGE 4• TOPIS v z-'1r-nwr 'n' C s PAGE 5 . V .. PLUMBER• �1� � or DESIGNER HOMESIIE SEPTIC PLUMBING CO. ! ItT.a O'NEIL RD.,HUDSON=WIS 5016 1 P 0,P4P T-5 0/,5 , _��10--3 ROBERT ULBRICH, WIS. P NN.NS AU�R&DESIGNER LI N0.®O6fi3 DATE: !� SIGNATURE RECEIVED JUN 30 1986 Plu 'G BUREAU soccr/ov Pear f kcv c A 5 Y 5 7-f-M ,0 7-/e,I L 7iPE,v c f/�'s To .C3� Sr- CA401X rQvvT� RE CEIVED JUN 30 1986 �,pEyiovs �/4Ty,�� ' i G BUREAU 11,4 rya v 10-5 86 - 03649 3 Fresh Air Inlets And Observation Pipe 'EMOV�D �• Approved Vent Cap ?,P6,000s,ED e;V1-rAEv Minimum 12" Above GR,40,- Final Grade /D 7 Q �' fr I IPRVOS16 1914o v-oT p " loam, fill 4" Cast Iron r /$ � Above Pipe — �g '� To Final Grade Vent Pipe Fr Synthetic Covering �X;ST%��– �' /O ZZ . I - Min. 2" Aggregate Over Pipe Distribution Tee Pipe 11 Aggregate o Perforated Pipe Below Beneath Pipe Coupling Terminating At Bottom Of System R`u ���® !-rt 'j" - i 0 7<Y- iA J ,1 �tiE .DE�.tI,f F 1��Gcr- o f 2 l r111 R40r P/ASV WER1 i('EiV �'c�o Er1zE •��°O J'�c T' SE T e- /its U3 ZZ � S �/3.so�°?'iov ��T.y�T ��"�,� �v�u; �c'�c��►o.�o �vrs . S o 'x,So �,5-- o PaR cgP,gc;Ty boo o �a.2 c 90 3649 /000 by STAB ��� c 0 VE 2 7-• Soy "• -- RFfi• 5-0 o F e PL � P 3 97 - - - - - - - - - , �R 1 . � y ' 5 izc o� Pep Sai t TES t . T a o P - �l /T/ �� � /v O �'• � �''+ v,� a^'mil #4.� ,}C� ��Irri h� � 1 j i +N /�ID �l�s1Sv�P��,B/E FtECE�vEO E .^ SyS%�'I A A4771- PyUM3l �EvR 3 --' .sc�lE / OA - 30 P,4 6�,!E7- -2- of L _ LLHR . Safety and Buildings Division PLAN APPROVAL Bureau of Plumbing P.O Box 7%9 ❑ General Plumbing Plans Madison,WI 53707 Private Sewage Plans 6 7 Telephone:(608)266-3815 `�G� !��7► co 9 � Project Name Project Location - Street No. or Legal Description 5 - L ; ❑ City ❑ Village Town of: ---'�-�' c� ;r C.. JZ a r The plumbing plans and specifications for this project V,e been reviewed for compli ce with applicable code require is approval is based on Chapter 145,Wisconsin Statutes and the Wisconsin Administrative Code.The plans Iona y approved".This approval is contingent upon compliance with any stipulations shown on the plans.All items that are noted must be corrected.All permits required by the city,village,township or county shall be obtained prior to construction.The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site.The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g This approval will expire two years from the date approved below.If construction has not commenced before the expiration date, new plan approval must be obtained. FOR PRIVATE SEWAGE PLAN (1) (2) (3a) (3b) (4a) (4b) (6) (7) 'This approval will expire ire two ears p y f�rom'the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only.All other system reviews must be submitted to the Bureau of Buildings and Structures. Comments: By: Q James Sargent Bureau Director i If Questions Plans Approved By: �. Date A proved: �. Contact ♦ ,,,�,,.�'. ) ,•�'�—•s- ,+ � � ! cc: Private Sew ge Consultant ❑ Plumbing Consultant ❑ Environmental Health li County _ ❑ Local PI ❑ Facilities Need Analysis Section ❑ W-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099(R.01/85) 11 Owner 11 Other