HomeMy WebLinkAbout014-1013-90-100
St. Croix County Planning and Zoning Tuesday, March 21, 2006 at 9:43:56 AM
Page 1 of I
Detail Sanitary Information
Computer 014-1013.90-100 Sub/Plat: NA Section: 6
Parcel 06.31.15.91F lot: 1 TNIRNG: T31N R15W
Municipality: Forest, Town of CSM: Vol. 06 Pg. 1595 114114: SW 114 SW 114 - -
-
Owner: Monson, Deny 2614 Cty. Rd. 0 Clear Lake, WI 54005
State Permit: 75028 Issued: 0311411986 POWTS Dispersal: Mound Permit: New
County Permit: 0 Installed: 0311411986 POWTS Detail: NA Bedrooms: 3 WI Fund:
POWTS Pretreatment: NA
Notes
Issuerlinspector As Built Plumber Other Requirements Additional Notes Money Owed
Harold Barber Yes Smith, Gale Tom didn't have date of inspection or any data on $0.00
report form, but wrote elevations on cover of file
Tom Nelson Signed Off: No folder. No as-built by Smith, either. 3120106 -
found as-built in separate folder with no date or
plumber signature to ID it.
Maintenance
Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification
311412006
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
c
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER e- RR 0 &r of N TOWNSHIP., 2" SEC. ~ T N-R_/J-W
ADDRESS iffl, ST. CROIX COUNTY, WISCONSIN
d k eAm L,gke 4.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
co.
V Rine Gc~,4y
/,v el-4
14'r Al d
to `
M d u ivd
s~y sre M _
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side o Rear, O feet
From nearest property line Front 10 Side,0 Rear, O feet
Number of feet from: well building: _
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity: 8d e
Pump Model: QSP ,,Z.? Pump/Siphon Manufacturer: Memo u 4j,;e 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, Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:-
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: Length: Number of Lines: _ Area Built: Zh6
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 P't.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEP 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 be ed o any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: apacity:
Number of rings used: evation of bottom of tank:
Elevation of inlet:
Number of feet from arest 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:
3/84:mj
IN
DEPARTMENT OF REPORT ON SOIL BORINGS AND
LABOR DUSTRY, SAFETY & BUILDINGS
HUMAN REDLATIONS PERCOLATION TESTS (115) DIVISION
P.O. BOX 7969
(H63.090) & Chapter 145.045) MADISON, WI 53707
LO~TTI~ON::~/~ FE ~j N ~J~ W TOWNSHIP/MUNICIPALITY: LOTNO.:BLK.NO.: SUBDIVISION NAM
E:
N'%.7r1/ ro' J '•7 ((or) n COUNTY: UYER'S NAME: ~r ...r
MALI G ADDRESS:
i
USE ~ Gc%- Syaos-
NO. BEDRMS.: COMMER IAL DESCRIPTION: DATES OB ERVATIONS MADE
Residence ? New ❑Replace PROFIL DES R PTIONS: I N TESTS:
...7
RATING: S= Site suitable fors stem
Y U= Site unsuitable for system
ON~VFNTIONAL: IMOUND: U j,t,._,,,mL)Ur`JL-WHI:SSUlRE: S 110 STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM-I ptional)
UU ❑
SS ~SIkU OSLII S❑U
If Percolation Tests are NOT required DESIGN RATE..
under s.H63.09(5)(b), indicate: FFloodplain, ny portion of the tested area is in the
indicate Floodplain elevation: -"Now"
PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO
NUMBER DEPTH IN, ELEVATION ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBESS ON BACK.)
s
3
7S" c '
A10 > c9- 01-6-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH, W IN HOLE TEST TIME
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. DROP IN WATER LEVEL-INCHES
PERIOD 1 PERIOD 2 RATE MINUTES
P- P R PER INCH
P &
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distan
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all bor' r re the hens
of land slope, a dire a percent
SYSTEM ELEVATION
i
1 _ r r
1
1, I I i If
I
i
f -
i i ~ - -
i ~
1 ~ i !
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print
TESTS WERE COMPLETED )l
N:
ADDRESS: ~ ~ 3O
CERTIFICATION UMBE PHONE NUMBER (optional):
v~ 7 3
CST SIG URE:
31STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
)ILHR-SBD-6395 (R. 02/82)
-OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be,a complete anti accurate soil test, your report must include;
1. Complete legal description;
2. 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;
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;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
J. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if appropriate; ' lace N.A. in the appropriate box;
10. If the information (such as flood plain, elevation) does not apply, p
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 34 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Other Symbols
Soil Separates and Textures
st - Stone (over 10") BR - Bedrock
cob Cobble (3 - 10") SS - Sandstone
gr - Gravel (under 3") LS - Limestone
"s - Sand HGW - High Groundwater
cs Coarse Sand Perc Percolation Rate
med s - Medium Sand W Well
Is Fine Sand Bldg - Building
i Greater Than
-
Is -Loamy Sand _ Less Than
sl - Sandy Loam ~
Bn - Brown
-Loam
sil - Silt Loam Bi- Black
si - Silt Gy - Gray
y Yellow
cl -Clay Loam
scl - Sandy Clay Loam R Red
sicl - Silty Clay Loam mot - Mottles
sc Sandy Clay wl - with
rr \ ~i
sic Silty Clay, fff few; fine, faint
-
#c Clay cc common, coarse
pt Peat : mm - Many, medium
m - Muck d - distinct
p prominent
HWL - High water level,
Six 1gbn'eral soil textures " surface water
for. liquid waste disposal BM - Bench Mark
VRP - Vertical Reference Point
p
1 ~
i
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit.'The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must 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 apy construction.
umsconswi ~ ■ SANITARY PERMIT
..7..7
. Count'
ILHRGROUNDWATER SURCHARGE
[Sanitary Permit No.
,7o5-0,2, Y
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly 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 included the creation of
surcharges (fees) or a number of regulated practices which can effect groundwater. The
surcha ge took a ect on July 1, 1984. All of the water that is used in your building is returned to
the gro ndwate through your soil absorption system or the disposal site used by your holding
tank pu er.
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-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
Ground 'I
jignat re of Issuing Agent: Groundwater Fee: Date: WIScO "
1, V
buried?
DILHR S8D-7289 (N. 05184)
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
a g
x 796-2239 (HAMMOND)
` 425-8383 (RIVER FALLS)
HAMMOND, WI 54015
September 10, 1985
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the Wayne Kaczmarski property lo-
cated in the SW14 of the SWk of Section 6, T31N-R15W, Town of
Forest, St. Croix County, revealed suitable soils at a depth of
33 inches, below which seasonable high ground water was noted.
This site should be suitable for a mound system.
Should you have any questions, please feel free to contact this
office.
Sincerely,
&rna4)
Thomas C. Nelson
Assistant Zoning Administrator
mi
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township- t~ret~x•
SW 41 SW 34 S 6 T 31 N/R 15 )BW Forest
Street Address: St. Croix
Subdivision: County:
Landowners Name: Mailing Address:
,Wayne Kaczmarski Clear Lake, WI 54005
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, 1
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
Signature of Applicant Date
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF
This day of 19
r
Notary Public, State of Wisconsin
DILHR-SBD-6413 N. O My Commission Expires:
w
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 79699 MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location sw_ l/q, sw 1/4, Sec. _ 6T 31 R_~ €W
Town llfihliIl~ Forest Street Address
Lot No. Block Subdivision
Landowner's Name: Wayne Kaczmarski
The application for this site is for:
® new construction use.
❑ replacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
~..1to have one of the first five approvals guaranteed for this year. This is
number - - of those applications. (Use one of the first five
quota numGers ssueU-t you.)
I.Xione of the applications needing a quota number. The quota number assigned to
this application is 59 - 19 - 6
❑ for one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
D for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department.
for an application on file prior to February 1, 1980.
L_.,] for a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is
replacing:
❑ a failing conventional soil absorption system.
❑ a holding tank that was installed and in use prior to February 1. 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a
conventional private sewage system, check here.
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Nelson $i re
County 0 ficial
Title Assistant Zoning Administrator' Date September 10, 1985
DILHR-SBD-6158 (R 12/82)
w,=-T
DILHR
PLAN APPROVAL Safety and Buildings Division
Bureau of Plumbing
❑ General Plumbing Plans P-O Box 7969
p~ Madison, WI 53707
iQt Private Sewage Plans Telephone: (608)266-3815
I
gaup
_ '"Y, YO
/3
Per-t~. P
Project Name Projeocation - Street No. or Legal Description
~e wr 0 N sp n/ . r?s. S 5 Gt/
3
❑ City ❑ Village Town of: :=County
f"o ~ es
The plumbing plans and specifications for this project have 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
approval must be obtained.
FOR PRIVATE SEWAGE PLANS: (1) (2) (3aj 3) (4a) (4b) (6) (7)
This approval will expire two years from the date proved 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:
James Sargent
Bureau Director
If Questions Plans Approved By:
Contact y Date Approved:
Z 2--
cc: 9 Private e age Consultant ❑ Plumbing Consultant ❑ Environmental Health
County ❑ Local PI ❑ Facilities Need Analysis Section
❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture
DILHR-SBD-6099 (R. 01/85) ❑ Owner ❑ Other
Smith Plumbing & Heating PHONE (715) 265-4838
«Sk,1 y>~ S4i See G NWOOD CITY, WISCONSIN 54013
D(Orrr tn 004 son Cleo, Zsvke~ 4.,oo~-. A-voc
$~nCi rh AW k, lvjq i
Tree
17 GSM a
4*0Mofa • Pic
eft-ma
M000081
y
bell,
\NG P
PwMe ~~,1, env 1 ~r+ o t
~s ~ ~ ~R t~NB p1NG 1000
QF \N S r
QPR~ME~Q\~\S\0 ~ ,J ISbt ~
pE G~~.Et~ S4'
5 ~ bec~ roo M
~C
JAN 1
Page Of
Straw, Marsh Hay, Or
Synthetic Covering
I Distribution Pipe
Medium Sand
Topsoll
F
3 E
PLUMBIN b
Slope
Bed Of Zy- 2 Force Main Plowed
Aggregate From Pump Layer
E L, -L,
PC2fir.. } LAG`~R P'n NUMAS REEAT►ON9
1LD1NG D '
OF I~,DU,TR AID
DEPARTMENT OF SA
DIVISI
ENCE ross Section Of A Mound System Using E
E CORRESPOND A Bed For The Absorption Area F Z
G f0/
Signed:
B~ Ft.
License Number: 1yl1V,!3-1f0 I o Ft.
Date: J Ft.
K Ft.
Alternate Position L46
Ft. W000 8 1
of -
Force Main WAY.yf Ft.
L
N
d Observation Pipe
L'- 6 K
A
w o
Distribution ~ ivtt~irr
Bed Of 2% - 2
2
Pipe Aggregate
~h
Observation Pipe Permanent MarkersC
JA jaut
R~
. ptU~RrNr.SF~T~~N
Plan View Of Mound Using A Bed For The Absorption Area
Page Of
Perforated Pipe Detail
End View
End Cap)) d )PVrf00led
1. C Pipe
Moles Located On Bottom,
S Are Equally spaced
* PVC Force Main
From Pump
PVC
/ Manifold Pipe
Distribution Alternate position of
pipe Force Main From Pump
Last Mole Should Be
Nest To End Cop
End Cap Distribution Pie La
Pipe Layout
8 @VO0081
Ste.
X _4&/T.
Signed: 7 Hole Diameter X ~Inch
License Number: Lateral / N Inch(es)
Date: Manifold Inches
Force Main 04 ~ Inches
PLUM6ING
i6w n RELA-"OHS
I;'~ DINGS C
DEPARTMENT 0, aD
Divisi r JAN 1
COQE'PONDENCE, p~U ~86
sEE MIgINr; ~S~rTioN
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS PAGE OF
VCUT CAP
4"C.I. VENT PIPE
WE.AJ FIEK PKOO_F -APPROVED LOCKING
} 25' FRCM DGOR, JUAICTIOh] BOX MANHOLE COVER
WINDOW OR FRLSH 12"MIU.
AIR IWTAKE~ I
GRADE
I I B" M I A1~,+
COWDUIT
INLET PROVIDE
AIRTIGHT SEAL,, ,~,c I I I
PLUMBING
A
w1C.-.L. PIPE. PPKOYEU JGINT A z I III APPROVED JGjo
EICTE~UING 3 I III W/C.I. PIPE.
ONTO SOLID ;r.,ll. - - 71 r 1 I I I ALARM EXTEIJOIAIG
B ` I I I ONTO SOLID b,
I r 's3
D PP,RTMENT OF D"u ST tY, LR6` f A607 'j REL'AIlM ( ( Oti
DIVISION `r SAFETY c'Jl!_SINGS
- I
S PUMP_, - J OFF
O _
- I R
COUCRETE BLOCK FC
RISER JAN 10 198
EXIT PERMITTED GIJL4 IF TAUK MANUFACTUREK HAS SUCH APPR q1 v
6PECIFICATIOUS NGSEcrioN
"TIC Arlo 185,80 o o o 8 1
E TANKS MAIJUFACTUREK: r NUMBER (_)F UUSLF,:
- P E K DA !J
1AAJK .,ILE 00 GAt_LOUS DOSE VOLUME:
!-,ALLiUK1S
ALARM MAAIUFACTUKEk:
CAI'ACITIF:`.,: n= 11JC14Ej QR
~i~At tCi'~
MODILL ►JUMbEK:
- 8- _ ~_~_IAICHES UR UAlt.r~►.I
SWITCH TYPE:
< __INCHES OR , GALLOk
--y/ry - - - _
I'LIMI' MAI,lLIf At " I UI<F K: J
U= ~IAJLHES OR GAL. C; K,
M01,1 L MtJMbLK: o.~-
- NO'I-E: PUMP ANO ALARM ARE TO BF.
Ou SEPARATE CIRCUITS .
f'UMI' UIyLHAI<hL KA'i`L
- GI'M
VEKTICAL. DIFFCI,'LNCE bETWLLU PUMP OFF AIJD DIS`IItIBUlIGIJ f1F'E ~/f~4_ FEL1 ,(p
+ MIMIMUM NETWORK SUPPLY PKE ;,,,-ik E . 2.5 90
t~~~,
FEET
40 _
t - F•E. E 1 0F FGRCE MAIN X 1 I
rl_FKIC [iCal FAcrnK~._~~ FEE-1_ 1~2 y O-~✓'
IOIAL U WAMIL,. HEAD *I- FEET
• ► r 04% L A i p
HYDR-0-mark
PUMPS SECTION 100
DIMENSIONAL DRAWINGS
• & PERFORMANCE DATA
MODEL: OSP33 SUBMERSIBLE SUMP PUMP - MAX. SOLIDS V SPHERE -1750 RPM
• TOTAL
HEAD Lit. No. 113.5 348
FT.
IN A 3/lo HP MOTOR
24
22 ti
20
18 9AgC,r
16
14
12
10
8 - - -
6 ~ -
FULL LOAD
4 AMPS AT 115 V.
2 6.5
0
10 20 30 40 50 60 _
U.S. GALLONS PER MINUTE 860,0 0 8 1
MODEL: OSP33 319
4 7
4h O
O
O 51/4
O O
91/4 O
4
O
11/4 STD.
25/16 PIPE THD.
AVio98
s
NOTEpI~MR~N~.SF~T
: CASTING DIM. MAY VARY'E VIV
H
ST C- 105 r~
r
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County °
z
d
a
OWNER/_21MR_ Ce 1? f?V &&V off/
ROUTE/BOX NUMBER Fire Number
.CITY/ STATE ZIP--'3 LVp6115_
PROPERTY LOCATION:_ &I Section T,?Z N, RI_r--W,
Town of OR ifS, 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. y
0
I/WE, the undersigned, have read the above requirements and agree n
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- It
ment of Natural Resources. Certification form must be completed
and returned to.the St. Croix County Zoning Offkf-e within 30 days
of the three year expiration date.
SIGNED
a -
DAT E 3 0`60'
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.
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/contracWX,("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.
- - - - - - -n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property 1 Section T _V_ N - R W
Township
Mailing Address 7
1.~.~ -z. .sue o a
Subdivision Name
Lot Number `
Previous Owner of Property 1y A Ytii5L, J"'X1 , JA LS
Total Size of Parcel ~Cf!
Date Parcel was Created - Z--
Are all corners and lot lines identifiable?^ Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE 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) eenti,by that a t etatementa on this bonm ane true to the beat ob my (oUA)
knowledge; that 1 (we) am (ahe) the owneA(b) ob the pnopenty duotibed in th,i,a
knbonmation bosun, by vi&tu.e ob a wa4 a.nty deed neconded in the Obbice ob the
County Reg.i,eten ob Deeds ad Document No. ,p! ,S"' ; and that I (we)
pus entty own the pnopoded site bon the d age poe aydtem (on I (we) have
obtained an easement, to nun with the above descA bed pnopenty, bon the
condtnuati.on ob aai,d 6y4tem, and the tame had been duty neconded in the Obbiee
ob a County Reg.cbteh ob Deeds, ab Document No. ! ) ,
SIGNA OF OWNER SIG TURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
St. Croix County Planning and Zoning Thursday, A.nuary 26,2006 at 4.53:19 PM
Page 1 of 1
Detail Sanitary Information
Sub/Plat: NA Section: 6
Computer 014.1013-90-100 TNIRNM: T31N R1 5W
Parcel 06.31,15.91F tot: 1
CSM: Vol. 06 Pg.1595 114114: SW 114 SW 114
Municipality: Forest, Town of
Owner: Monson, Derry 2614 Cty. Rd. Q Clear Lake, WI 54005 Permit: New
State Permit: 75028 issued: 0311411986 POWTS Dispersal: Mound Bedrooms: 3 WI Fund:
County Permit: 0 Installed: 03114/1986 POWTS Detail: NA
pOWTS Pretreatment: NA
Notes Other Additional Notes Money Owed
Reouiremerrts
Issuerllnspecior As Built Plumber Tom didn't have date of inspection or any data on $0.00
Harold Barber No Smith, Gale report form, but wrote elevations on cover of file
Tom Nelson Signed Off: No folder. No as-built by Smith, either.
Maintenance
Scheduled Pump Date Pum 1st Notification 2nd Notification 3rd Notification - -
311412006
- - - - - - - - - - - - - - - - - - - - - -
MONSON, DERRY SW SW, Section 6
Clear Lake, WI 54005 T31N-R15W . FI15 0
~ .'eel Q Town of Forest _
San.Permit#75028 3-14-86 G. Smith
Mound, New
I
Parcel 014-1013-90-100 01/26/2006 04:47 PM
PAGE 1 OF 1
Alt. Parcel 6.31.15.91 F 014 - TOWN OF FOREST
Current X' 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 - MONSON, DERRY W & JANET S
DERRY W & JANET S MONSON
2614 CTY RD Q
CLEAR LAKE WI 54005
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2614 CTY RD Q
SC 1127 CLEAR LAKE
SP 1700 WITC
Legal Description: Acres: 5.380 Plat: N/A-NOT AVAILABLE
SEC 6 T31 N R1 5W 5.38AC LOT 1 OF CSM Block/Condo Bldg:
6/1595
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
06-31 N-1 5W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 760/86
07/23/1997 732/544
2005 SUMMARY Bill Fair Market Value: Assessed with:
94673 206,700
Valuations: Last Changed: 10/17/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.380 25,000 184,400 209,400 NO
Totals for 2005:
General Property 5.380 25,000 184,400 209,4000
Woodland 0.000 0
Totals for 2004:
General Property 5.380 6,500 113,100 119,6000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Chargeo
0 ~U ~U
Total 0.00 00
Parcel 014-1013-60-110 01/26/2006 04:46 PM
PAGE 1 OF 1
Alt. Parcel 06.31.15.9113-10 014 - TOWN OF FOREST
Current X 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 - MONSON, DERRY W & JANET S
DERRY W & JANET S MONSON
2614 CTY RD Q
CLEAR LAKE WI 54005
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 1127 CLEAR LAKE
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE
SEC 6 T31N R1 5W PT SW1/4 SW1/4 COM SW Block/Condo Bldg:
COR SEC 6; TH N 89 DEG E ALG S LN SW1/4
1325 FT; TH N 33 FT TO PT NLY R/W CTY TK Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
HWY Q POB; TH N 435.60 FT; TH S 89 DEG W 06-31 N-1 5W
300 FT; TH S 435.60 FT; TH N 89 DEG E
300 FT TO POB
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 876/376
2005 SUMMARY Bill Fair Market Value: Assessed with:
94670 10,400
Valuations: Last Changed: 10/17/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 10,500 0 10,500 NO
Totals for 2005:
General Property 3.000 10,500 0 10,500
Woodland 0.000 0 0
Totals for 2004:
General Property 3.000 5,000 0 5,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
.DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
❑CONVENTIONAL PALTERNATIVE State Plan I.D. Number:
❑ Holding Tank ❑ In-Ground Pressure IIf assigned)
Mound 8600081
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER
INSPECT N E:
Derr Monson Ctear Lake, WI 54005
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:
REF. PT. ELEV.: CST REF. T. ELE V7
SW SW Section 6, T31N-R15W, Town of Forest
Name of Plumber:
MP/MPRSW No. County Sanitary Permit Number:
Gale Smith 5690 St. Croix 75028
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
BEDDING: VENT DIA.: VENT MATT HIGH WATER OYES ONO OYES ONO
ALARM. NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH
DYES ONO FEET FROM LINE AIR INLET:
❑ YES ❑ NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL PUMP;SIPHON MANUf ACjh4 JklATERIA1 BEL LOCKING COVER
OYES ONO PROVIDED:
GALLONSPER CYCLE: PUMP AND CONTROLS OPERATIONAL ONO OYES ONO
(DIFFERENCE BETWEEN NUMBUILDING VENT TO FRESH
FEET AIR INLET:
PUMP ON AN D OFOYES ONO NEASOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing a,rJND MARKING
or excavation. (If soil can be rolled i nto a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF UISTH PIPE SPACIN(V COVEH INSIDE DIA a
THE NC HES MATERIAL PITS LIQUID
DIMENSIONS PIT DEPTH:
GRAVEL DEP H FILL DEPTH UISTH. PIPE DI S7H PIPE DISTR. PIPE MATERIAL NO DI$TIt
BELOW PIPES ABOVECOVER ELEV. INLfI ELEV. END -NUMBER OF PROPERTY WELL. BUILDING: V NT TO FRESH
PIPES FEET FROM LINE. AIR INLET:
MOUND SYSTEM: NEAREST
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 ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE
PF HM A N I NI MAHKF RS OffSEH VATI ON WELLS
DEPTH OVER TRENCH BED DEPTH OVFH TRENCH HEU U[PTH OF iUPSOIL SODUFD DYES ISEEDE5OYES ONO
CENTER EDGES MULCHED
OYES. ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH vIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PI
PF FILL DEPTH ABOVE COVER
TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO UISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV. DIA. ELEV. PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHE C TLV COVER MATERIAL
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL
NUMBER : BUILDING:
OF
FEET FROM LINE:
DYES ONO DYES ONO NEAREST"
Sketch System on Retain in count file for audit.
Reverse Side. Y
SIGNATURE. TITLE:
DILHR SBD 6710 (R. 01/82)
Z wIsConsin d 1.
. D' ~ APPLICATION FOR SANITARY PERMIT
DEPRRTrnEnTOF (PLB 67) COUNTY
Z LHR
InOUSTRY, LRBOR E, MUMRn RELRTIOns
UNIFORM SANITARY PERMIT #
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system on ~SQ
-See reverse side for instructions for completing this
R application. PLEASE PRINT paper not less than 8'/Zx 11 inches in size.
~qq POPER TY OWNER
MAILING ADDRESS
PROPE TY LOCAT N 6
eJ 1/4SQ1A S T
LOT NUIII ER BLOCK MB SUBDIVISION NAME TOWN OF:
NEAREST ROAD, LAKE OR LANDMARK
t// STATE PLAN I.D. NUMBER
C.~Oct./h
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms: a lq
❑ Public (Specify):
THIS PERMIT IS FOR A:
New System
Replacement Soil Absorption System ❑ Tank Replacement ❑ Repair
❑ Alternate System ❑ Revision ❑ Privy
❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench
System-In-Fill ❑ ❑ In-Ground Seepage Pit ❑ Holding Tank
Pressure ❑ Vault Privy
❑ Existing, For Which A Previous Permit Is On File, Permit ❑ Pit Privy
El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. issued
Total #of Prefab.
Gallons Tanks Site
Septic Tank Capacity Concrete Constructed Steel Fiberglass Plastic
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEPJI COMPLETE THIS BLOCK: Mound ❑ In-Ground Pressure
Total #of Prefab. Site
Septic Tank Capacity Gallons Tanks Concrete Constructed Steel Fiberglass
Plastic
Lift Pump/Siphon Chamber
Manufacturer-
PE COLATION RATE ABSORPTION AREA
(Minutes per inch): REQUIRED ABSORPTION AREA
(Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
.375' 376
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):
Signatu
P C-1 PRSW No.: Phone Number:
Plumber's Address: 90 ( ,
Name esigner:
~rV
Signature of Iss f COUNTY/D
EP RTMENT USE ONLY
uing Agent:
/ Fee: Date:
3 ❑ Disapproved
Reason for Disa Approved ❑ Owner Given initial
pproval: Adverse Determination
X8000 8
Alternate course(s) of Action Available: JAN 1
P"JAMAIG SFrT101y
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:
ert owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
1. Prop y
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.);
om lete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
3. C p
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 ll install theure b ockircle the appropriate license classi-
fication, place your license number in the space provided and 9 the permit in the sig;
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.
e size, separating distances, distances between beds if appropriate, tank locations, effluent line fro M' tank(s)
14. Piping detail including pip :t
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.
stio s
mu concern ng
THE OWNER: This valid for two years. Changes in youse Iic tank whenever necessary usually very 2 to 3 years. lf you have quet c
must be properly maintained. Have a licensed pumper clean your pt
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
~ DILHR
PLAN APPROVAL Safety and Buildings Division
Bureau of Plumbing
P.O Box 7%9
❑ General Plumbing Plans r;
I J$ Madison, WI 53707
Private Sewage Plans; / Telephone: (608)266-3815
f ~ ' VfTl
2 F
L 41
6
i 40
T
_ Rewiew F60-. a6b
R +v .
Project Name Project Location - Street No. or Legal Description
1~ •,t/r
i y. t f tr r
County,.
❑ City ❑ Village
~j Town of:
f.,
The plumbing plans and specifications for this project have 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
approval must be obtained.
FOR PRIVATE SEWAGE PLANS: (1) (2) (.(3a)j(3b) (4a) (4b) (6) (7)
This approval will expire two years from 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:
James Sargent
Bureau Director
If Questions Plans Approved By: Date Approved:
Contact
' - J
cc: 1~ Private Sewage Consultant ❑ Plumbing Consultant ❑ Environmental Health
IX County ❑ Local PI ❑ Facilities Need Analysis Section
❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture
DILHR-SBD-6099 (R. 01/85) ❑ Owner ❑ Other
a9
SBB 6678. (R. 08/83) (Plb 100a) (Wis Stats. S. 145.02)
STATE OF WISCONSIN DILHR
Detach-And Return Upper DIVISION OF SAFETY & BUILDINGS
Portion' Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 141
Any Return Correspondence P.O. BOX 7969
8 MADISON, WI 53707
608-266-3815
DATE: v9 JECT:
U1/10/8
ionson, Uurry - kesiderice
a(b)
5m, Sw, ti, 31,15W
2 \ Tr; Furest
Smith Plumbing :1 Heating St. Croix iv1
Route 2
Gl enwuod City, W! 54013 PLAN ID. #
86-OU081
DETACH HERE
PROJECT NAME_L~ifinSon. berry - kr?si lrrnrt;, PLAN ID. # 86-00081
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ Fee Received is $ 60-1)0
Plan accepted for review. ❑ Underpayment- Please submit additional fee. Plans will be held in abeyance.
❑ Plans being returned. ❑ Overpayment-Refund forthcoming.
❑ Additional information required. SEE BELOW. ❑ No fee has been remitted. Plans will be held in abeyance.
1. Plan Submission ❑ Soil boring and percolation test data on 115 completed
❑ Additional information shall be submitted in duplicate unless by Certified Soil Tester. (1 copy)
specifically noted. ❑ Petition For Modification signed by county, owner and
❑ Plans not clear, legible or permanent, notarized. (1 copy)
❑ All information submitted shall be signed, dated and sealed or ❑ Complete data relative to anticipated use of building.
stamped in accord with Section ILHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required. (1 copy)
Administrative Code. ❑ Affidavit enclosed. El Condominium declaration.'(1 copy)
Plot plan showing location of land parcel (distance from
nearest road intersection, etc.), lot size and all distances from IV. Holding Tanks
private sewage system to buildings, lot lines, well, water- ❑ Holding tank profile showing vent, manhole, alarm,
course, swimming pools, water service piping, all weather ser- and manufacturer if state approved. Complete
vice road, etc. Show benchmark with permanent elevation. construction details if site constructed.
❑ Holding tank agreement signed by owner and local
II. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed).
❑ Application for Use of an Alternative System signed by owner ❑ Reason for installing holding tank. Statement from
and notarized. (1 copy) county or soil boring and percolation test data on
❑ County onsite required. (1 copy) ❑ Design calculations. 115 completed by CST; showing that a soil absorption system
Soil boring and percolation test data on 115 completed by cannot be installed on the land parcel
Certified Soil Tester. (1 copy) ❑ Affidavit for all-weather service road (enclosed).
❑ Cross section of system. ❑ Pipe lateral layout.
❑ Plan view of system. V. Dosing Information
❑ Verification fo Exception Status Form by county. (1 copy) ❑ Calculations for total dynamic head and gallons
pumped per cycle.
III. Private Sewage Systems ❑ Size, length and depth of force main.
Ground slope with 2' contours in entire area of soil absorption ❑ Detail and model of pump or automatic siphon, including
system extending 25' minimum on all sides. size, pump curves, drawdown, and average flow rate (GPM).
❑ - Location of area suitable for replacement system - provide.soil ❑ Cross section of dosing tank showing pump(s) or siphon(s).
data.
Construction details of septic, holding or dose tank if site VI. Systems in Fill (Fill must be placed prior to plarr submission.),
constructed, or tank manufacturer if state approved. ❑ Total area filled (fill to extend 20' beyond edge
❑ Construction details and cross section of soil absorption of trench before side slopes begin.)
system.
❑ Depth and type of fill
❑ Copy of signed onsite report by county or district staff.