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CROIX COUNTY, WISCONSIN SUBDIVISION 60,11iou.i era%! LOT S7 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /Vo ~p,° sGr 50 611 a1 Trtr e1,eS Jrx 6o 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 0 Rear, O feet From nearest property line Front 10 Side,0 Rear, O feet Number of feet from: well _/2 0 building: ! ~r (Include this information of the above plot plan)( 2 reference dimensions to sentir tank) Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT Form - S T C - 104 OWNER o,-n Z 6"~ BUILT SANMMjBTE SEC. Z8 T ~N-R_~/ _W OWNL*DR !Roe e1j1 TOWWIZR0&_d wT crnueIVC • Z9 T ZJN-R ~I W ADDRESS K l.~~U ;~,6CROIX COUNTY, WISCONSIN SUBDIVsdjrf(at/ 4X LOT ~y LOT SIZE 777 SUBDIVISION 60,11iow eras t LOT pT.AJ , TF.W LOT SIZE /v Distances and dimensions to mee$LMgAF&ents of IL-HR 83 Distances and dimensio80O%cEN TRTW#PFM s19 i IV SYSTEM SHOW 77 7 77' 77-~ vices 1P~~sS 1, /v S I y 19/ 0 • ~s A 0 roll f(I 01 ~~rcr/S s ,fix 5v INDICATE NORTH ARROW INDICATE NORTH ARROW Describe the vertical reference point used Cvr Pr o-- oB1 ~tlt~lt @f~4 t }~oti ren point used,r eat--111.14 =sitiej.~_~ moo. eP- Fla f vertical reference poi t. Proposed slope at site: SEPNgC: Manufacturer: Liquid Capacity: /p c.) . SEPT m bf P►'~ 4iiWfler: _ /I' k-~ e~egcoveraucieva t 3 ftK%te1in4ttrft%q,at~l8M bu ~e eE~evationevation: W61%tejnbPtf§jfv?tA91n,;_2rQRt RoAgnk Futle t ront, Me R"aiL --feeet Number feet fr m neare t Road: Front Bide, Rear, feet F?9m nearesg proper y line Fronts Side Rear, feet NumberFcrpmf rj?pS.pro ty ftr, ' bu tt Side Rear, feet (Inc ude thi nfo tion o er o eetrrr wefl1the boy3e . PlQDU1i'1Q;( 2 r Wence dimensions. to septic tank) um c_,....tis. _ .a ~i,, t,,..,. ...~r SEE,REVERSE, SIDE t PUMP CHAMBER r • 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: Leng"""th: Number of Lines: Z_ Area Built: 5_x0 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, F't. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: A'# 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, QFt. Number of feet from well: J Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: r- i s•.~ Dated • /6 - 2/ Plumber on job: • License Number : 1/~~'S 3 vl` 3/84:mj EPARTM,ENT OF RNDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION .O. BOX 7969 BUREAU OF PLUMBING ADISON, I i' 53707 KRCONVENTIONAL ❑ALTERNATIVE Slate Planl.D.7mbet'L 111 a..1pned) Holding Tank ❑ In-Ground Pressure ❑ Mound ZNAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DATE 10: -90 1 Tom Parker Rt. 3, N. River View Pass, Hudson, WI BENCH MARK IPermanem reference pomtl DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF PT ELEV NW NW, Section 20, T29N-R19W, Town of Hudson, Lot 454, Willow Ridge I .n. n/Plwnlter_ MP/MPRSW No.. County- Sanitary Perms Numlxr: Roger Timm I3224 St. Croix 88394 SEPTIC TANK/HOLDING TANK: L MANUFACTURER Oul A f TANK INLET ELEV. NK OUTLET EL WARNING LABEL JLOCKING COVEN PROVIDED PROVIDED 75- ❑YES ONO OYES ONO 1BOYES EDDINGVENT NT TL ATEH NUMBER OF ROAD: ERTY JWELL BUILDING VENT TO FRFSH LARnT FEET FROM IAIR INLET ONO ❑YES ❑NO NEAREST OSING CHAMBER: [GALLONS AN"FAC T UREH JBFDDING LIOUtU CAPACITY 1pukipMOUEL -----Jump SIPHON MANU/ ACT0111H WARNING LABEL LO OCK IN CCOVER PROVIDED PRVIDED ❑YES ❑NO ❑YES ONO ❑YES EINO PER CYCLE: PUMPANO CDNTROLS OPERATIONAL NUMBER OF VIII"'f R1y WE LUII DIN(: VENT $H DIFFERENCE BETWEEN FEET FROM LINE AIR N1I I UMP ON AND OFF) ❑YES ONO NEAREST> OIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE I F NI,111 IllAMf 1111 vnl l Hb1I ANC n'AIIKIN`' r excavation. (If soil can be rolled into a wire, construction shall cease until e soil is dry enough to continue.) MAIN ONVENTIONAL SYSTEM: BED/TRENCH IVIDTH LENGTH INO OF UISTH PIPC SVA(:IN4 COV H JINSi01 •1 iV1iS 1 10011) 1 N THEy~Hes Mnr RIAL: PIT 1)frTH DIMENSIONS (,HAVEL 14-4 FILL DEPT F4 UIS 111111'! UI$TR PIPE DISTR. PIPE MATERIAL N%~V PHOVEHIV W,LI. HUILOING VENT 1111111':11 HF LOW PIPE t AHOY C VEH :11 f V IN f 1 ELEV ENU _ PINUMBER OF 1 0 LINE - O AlH yyl l T FEET / 1 1..51_ NEARESTO-► dS[J~ / ~CI OUND 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- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. OIL COVER TF%II1HE VfNMANfNIMAHKIH$ =11,N WIIIOYES ONO ES L11 NO DAP Tit OVE H THE NCH Of 1) 10*Pt 110017 THENCII BED hEVTll of TUVS0IL r_' )1U n1Ul(:IHU CTNIFR EfX:ES YES ONO DYES ❑NO OYES r PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIOTN LE NG111 NO.OF LATERAL $PACIN , (;NAVEL OF PiI/ HI LOW VIII f Il L UFPIH AHOVF COVI 11 TRENCHES DIMENSIONS MANIFUI.711L MP MnNlf01U UI$TR _PIPE MANYULUMA EIIIAI NCI I)ItiIH F S II 1'IVf nltiIJ111/1)1111NV"'1 111AItHIAI KRL111KINI, ELEVATION AND ELEb IF V CIA ELEV. rIPFS A DI STRIBUTION INFORMATION /IOLE SItF Hurl.SPACING ulu a LU COHHt C I I y COW IT MATERIAL Vf H I II:AI 111 t 1:0141-If SVI IN Uti III AVVIII IVI U rLnnls VERMANENT ARK R DYES ONO DYES COMMENTS: OBSERVATION WELLS NUMBER O LINE F PROPERTY WELL C) uODING FEET FROM ` ❑YES ONO ❑YES DNO NEAREST orio:K P ~ a .5 S 10~~ rte' s IL 5 e~ 1 , Oaf c 0L/ a 7^' r6 D ko. d a.'l f E t 0 /III ~ ~ aVe,~ ` q0 I o Sketch System on Retain in county file for audit. Reverse Side. SI(iNA TUNE TITLE DILHR SBD 6710 (R. 01!82) - SANITARY PERMIT APPLICATION CO T OILNR In accord with ILHR 83.05, Wis. Adm. Code . STgjE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER / PROPERTY LOCATION III&J/a, S Zo Zr, N, R 17 (or W PROPE~OVyNER'S MAILING ADDRESS ASS LOT NUM BE R BLOCK NUMBER SUBDIVISION JV~ ~ 4 CITY, STATEK/K l(ZZII/IP DOPE PHONE NUMBER CITY NEAREST ROAD, LAKE OR ND O7'I O~ li VILLAGE : T~f~CcF~CJ ~/t/ V I ~letJ ~Q MARK A4066 lia TOWN OF- II. TYPE OF BUILDING OR USE SERVED: vow '"'IltLS ~O - 0 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. ❑ New b. M Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a.]% Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. E1 Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. 9 seepage Trench C. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Q'o~ / ✓ U 10. -/-41 2 Feet qdPrivate ❑Joint ❑ Public VI. TANK CAPACITY in alions Total # of Site p INFORMATION ew Existing Gallons Tanks Manufacturer's Name Concrete Prefab. Con- Steel glass A Fiber- plastic App. N p. Tanks Tanks structed Septic Tank or Holding Tank ❑ ❑ ❑ Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: ((No Stamps) MPfMPRSw Nn. Business Phone Number: 77Z ° 3.2211 [Pumbers Address (Street, City, State, Zip Code): Name of Designer: ~~O Z SGT e VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # 6 CST's A DRESS treet, City, e, i Co e) Phone Number: Ism IX. COUNTY/DEPARTMENT USE ONLY Y❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Surcch/arrg-e Fee / Approved ❑ Owner Given Initial 4/4>0 Adverse Determination ~ y~ X. COMMENTS/REASONS FOR DISAPPROVAL: i f SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber 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 systei, 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: 1. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. 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; lll. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/s 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 Groundwater sncluded the creation of surcharges (fees) for a number of regulated practices which Wisco in's an effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure A ss used it: your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. The pnonies collected through these ~ircharges are credited to the groundwater `.~nd+ adminis- t terec by the Department of Natural Resources. These funds are used for mon for ; g, -ou.nd- qtr, .,!~:ater, groundwater contamination investigations and establishment of standards. OroUndwater, `S worth protecting. SBD-6398 (6..03/86) . 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 W k Ntj it, Section Zo , T?CJ-N-Rjq_ W Township Ll U i z~ n Mailing Address D X H Lt _soh (,J t =sq n a. Address of Site T- S 1-3> ox 33 u& Or'1 • Sy o t6 Subdivision Name i It D LO fem. t aC,Q' Lot Number Previous Owner of Property ZqA M l A Q be✓'iclse- l , Total Size of Parcel • 7 5 A Irce S Date Parcel was Created M(,~/v'c~f,, 7(2 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 5-7(3_ and Page Number 6 27 s 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 Resister 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 I (We) cexa6y that att statements on this 6onm arse true to the best o6 my (oust) knowledge; that I (we) am (arse) the owner(s) o6 the pnoperrty deschi:bed in this inbonmation bonm, by vi tue o6 a waiAanty deed seconded in the 066ice o6 the County Register o 6 Deeds as Document No . S 11 t ) and that I (We) pees ent.~y own the proposed site bon the sewage di spos . s ys em (on I (we) have obtained an easement, to nun with the above deschibed pnoperrty, bon the constnucti.on o6 said system, and the same has been duty seconded in the 046ice og the County Reg.isten og Ueed6 as Document No. SIGNATURE Old' OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) TATLQT/.TTL'•71 . H z • H STC - 105 r r a SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County 0 z OWNER/BUYER d` ~rlQrsh 1 aXKL✓ y ROUTE/BOX NUMBER FjpX33 Fire Number 073 CITY/STATE ~UdSor~ I,Jt ZIP _540((" PROPERTY LOCATION: 14h 14, 14, Section ZO T_.Zq_N, R)4q-W, Town of H kSt. Croix County, Subdivision`Jl i100 tam Lot number 5L4 , Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 I E, the undersigned, have read the above requirements and agree £ z to intain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b 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 JA-CCeri.- 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. L DEPARTME!qT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUS NDUSTRY, DIVISION N LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN, FI ELATIONS 1 MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/fe4 {dttl?XtCrfY: LOrTNO.:BLK.NO.:SUBDIVISION ~NAME: uGv ~4 4 W /1Z9 N/R E (or /~j/(/pi-ov J 4 ~//h4 Z 7 COUNTY- OWNER'S/+l+:I*&R'S NAME: MAILING ADDRESS: sT ehlx Iv. Aotei<v 1/0 7_6 41 //i2ci Ass 11k1oso,~ Cv..r. syctr6 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCR PTIONS: PERCOLATION TESTS: Residence ~f ❑ New Replace RATING: S= Site suitable for system U= Site unsuitable for system ✓ C ! ZQ ?1v~~ /oeOJ7-Q (O CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) z S ❑U © S ❑U 21 S ❑U ❑ S DU Cl S ZU T,PE.~iuEls ee O~P~fiv,~%Ec.~ If Percolation Tests are NOT required DESIGN RATE: [Floodplain, an I X) AG~ Y Portion of the tested area is in the under s.H63.09(5)(b), indicate: li Ss ..L indicate Floodplain elevation: ,PROFILE DESCRIPTIONS iN QEti.yitL ~-f , BORING TOTAL ELEVATION D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- D, v ,75 ' C f y S* S 8,u..r, , 7.0 - T.rr o B-2- 9 U' 7,7-6S " - > d ' o y ?~,v v cs w N > J V. 4_0 B- 50i1- Su iT.}~iG t j CORE- CO.Y /if,~CE Q lr&z s i 11MOP OW D p B_ g .s i c- Sysr V s / /,r d F S a` • N ZE s"7- 7- O B- 6 .v s. Cv p,~ ~y, s1 ry %s 7-0 PERCOLATION TESTS I0el-IC AW7"i 1'5IJ~---07_-ki_4V/1 TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER Hd~hFC-3' AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- • V C 3 >214 )z P- ti P- P- P~_ C 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~ N~ 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 percen of land slope. SYSTEM ELEVATION 00.s`S AU K 1110 Onr F*LE~ ~41 l I ~ Oe~ar~j 113 r , 91C'v`i^^ ~ ~ I p _ ~ f Y r E L"qp jo' ed M , , . , # 4 1~EU C E 36 j C ~ , ics , 3 1, the undersigned, hereby certify that the soil tests reported on this form y e in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the est of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. qG~ C~, 7► ~ ~ _ ~9d'G 121~30'NEIL RD-;W.l N, VAS- 5401 ADDRESS: ROBERT ULBRICHT .f• CERTIFuIC?ON NUMBER: PHONE NUMB (optional): WIS. MASTER PLUMBER LIC, N0.3307 M.P.R' 2- 2-- MINN. INSTALLER & DESIGNER LIC. NO. 00 cs GNATUR ISTRIBUTION: Original and one copy to Local Authority, Property Owner an 9ter. -SBD-6395 (R. 02/82) - OVER - INS `RUC ;JNS FOR J 1PL.FT I! [t 11 8 - T a. QI 2. i is 3. Asian; A it a_ iE 30 DA) a p1 I s ra R S y Timm JOB -T" of Z SHEET NO. &cavating ~ ~~Co• CALCULATED By DATE R 1, BOX 192, ♦T ilson1 ~Y l 554027 CHECKED BY SCALE v j 3 r~ 171 LI L .5- oMllllK^ )M , Inc. 6lotal. MIU 01111 _ JOB_----- Timm OF SHEET NO. CO, CALCULATED BY r OAtE 7 &,avating 37,2/ R I, BOX 192, Wilson, WI 54027 CHECKED BY SCALE i i z. o o tat] 5 aav,n,K~ A( AE Inc. 0.1. M- 01471. _ C - AS BUILT SANITARY SYSTEM REPORT a ,rAER~' J 4. M M!~ TOWNSHIP ~ u d S o n SEC .2 ~ T2 IN, R r b W P.O. ADDRESS ( r~ dfol~t , ST. CROIX COUNTY, WISCONSIN. 'SUBDIVISION IA/r f t6r,. i ti s y LOT ~ LOT SIZE • PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ti gel - L s1 l 2 _ Tell ~rnq $ f(o us e i GI SEPTIC TANK (S) l 0 0 y MFGR. e S e,- CONCRETE STEEL NO. of rings on cover J Depth DRY WELL TRENCHES NO. of width length area BED no. of lines width length area depth to top of pipe Z AGGREGATE PERK RATE , AREA REQUIRED AREA AS BUILT Z Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. z _'INSPECTO ..~.--L~ ~ DATED PLUMBER JOB LICENSE NUMBER m RFPOP.T Or IIISPECTION- INDIJIDUAL SEWAGE UISPOSAI, SYSTEti _~Iz 1z Sanitary Permit r State Septic ~'E T&INSHIP a " 4t. Croi;; Co `"'DTTC TAM' ' i Size ,0? gallons. "umber of Compartments Distance From Well 7-'ft. 12% or greater `72`.~ x slope~I. Building ' ft. Wetlands f: Highwater _ ft. DISPOSAL SYST H Nile Field or Seepage Pit(s) Distance From: 'Tell ft, 12% or greater slope / t Building .._ft. Wet-lands _ FIELD r~H"lFhwater ft Total length of lines v ~ ft. Number of lines Length of each line ft. Distance between lines ft. Width of the trench Lft. Total absorption area sq. ft. Aepth .of rock below the in. Depth of rock over tile Z- in. Cover aver rock, Depth of tide below grade Slope of trench in er 1100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS Number of pits ts'' d' meter ft. Depth below inlet ft. Gravel aro d ~i Yes no. Total absorption area sq. ft. .Square feet of seepage trench bottom area required 1 • %Cquare feet of see ni r required Inspected h Title: Approve Date 22- 197 Rejected Date 197. 5 `e P 6 State and County State Permit Permit Application County Permi # 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: 5AM ILI-1..~~ ~g B. LOCATION: '/4 Section T N, R E (or) W Lot# _%~_City _ Subdivision Name, nearest road, lake or landmark Blk# Village Township (J 3 v )y C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family V Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher L' YES NO Food Waste Grinder '---YES NO # of Bathrooms Automatic Washer V YES NO Other (specify) E. SEPTIC TANK CAPACITY b U Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _ Prefab Concrete *Poured in Place -Steel Other (specify) F. EFFLU NT DISPOSAL SYSTEM: Percolation Rate 1) i5 2)t5' 3~ 5 Total Absorb Area Z sq. ft. New Addition Replacement *Fill System See a e Trench: No. Lin . Feet 5 L Width Depth Tile Depth No. of Trenches Seepage Bed: Length 5.2 ` Width Depth 3 Tile Depth / No. of Lines Z Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land -4 76_ Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME _ k(C, k A RP W 6 ID ) US C.S.T. # 13 and other information obtained from (owner/builder). Plumber's Signature IyIP/MPRSW# M P - 'B-II Phone # Z ' " } .2 7 ~T Plumber's Address c tit a ~1 PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). L_ art ~ _ \1 ~r t, el, 33L Do Not Write in Spa blqw - FOR DEPARTMENT USE ONLY Date of Application `Fees Paid: State/0, y y Co nth. ~Date Permit Issued/ (date) ~`~_Issuing Agent Name Inspection Yes o 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) L Revised Date 6/1 /76 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS / LOCATION: kkV., Section .J_-17, T--,2-k, R -54 (or) W, Township or Municipality cam' S e7 s Lot No_ Block No. t e f/ County _5_2 1 e_ /~Subdivl qn Name Owner's Name: fa J), ~~I , /-F Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms- 3 Other EFFLUENT DISPOSAL SYSTEM: NEW t1_____ ADDITION REPLACEMENT DATES OBSERVATIONS MADE:: SOIL BORINGS_ ~-PERCOLATION TESTS •3 ~ 2 . SOIL MAP SHEET qo / SOI L TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES NUM- SINCE HOLE HOLE AFTER INTERVAL RATE BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P 3 Q 73 P-~ 3~ t l , l , t f ~ ~ ~ ~ ~ S^ P-3 36 6 s SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) 2 7 r• 5 2 I ~r c 71 c SS kr A, PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable a ea . ndi to numb f e feet of absorp{tio-Ca needed for building type and occupancy. 4 or distances. Give horizontal and vertical reference po nts. Indicate lope. r 1 t_ f' 1 t N a 44, 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 location of test holes are correct to the best of my knowledge and belief. Name (pr'nlt.) C, I- Certification No.-/ ~l Addresyt % e- t '/s t Name of installer if known' CST Signatur~ t C` l` COPY A -LOCAL AUTHORITY