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Parcel 026-1112-30-000 09/19/2005 04:56 PM
PAGE 1 OF 1
Alt. Parcel 3.30.18.638 026 - TOWN OF RICHMOND
Current Fx 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 - BORST, DARCY & SUZETTE
DARCY & SUZETTE BORST
1226 172ND AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1226 172ND AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.260 Plat: 2021-GREEN ACRES ADD
SEC 3 T30N R1 8W LOT 3 GREEN ACRES ADD Block/Condo Bldg: LOT 03
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
03-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
03/30/1999 600328 1414/558 WD
07/23/1997 892/142
07/23/1997 498/581 .~s~► A--
2005 SUMMARY Bill Fair Market Value: Assessed with: 7
0
Valuations: Last Changed: 04/22/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.260 30,600 111,400 142,000 NO
Totals for 2005:
General Property 1.260 30,600 111,400 142,000
Woodland 0.000 0 0
Totals for 2004:
General Property 1.260 30,600 111,400 142,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 519
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DILHR SANITARY PERMIT APPLICATION COUNTY
TO,:o~~,.,,. In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITWY PERMIT #
• -Attach complete plans (to the county copy only)' for the system, on paper not less than STATE AN N I:.DD . ,
8% X 11 inches in size. NUMBER
-See reverse side for instructions for completing this application.
PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROP RTY OWNER PROPERTY LOCATION
X S , N, R 1eq E (or~
PR E Y OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CIT , STATY1 ZIP C DE PHONE NUMBER CITY NEAREST OAD, AKE :OZ NDMARK
7 if ~ VILLAGE
i) r La/k- TOWN OF7 2a&= A
II. TYPE OF BUILDING OR USE SERVED: 41- /M . gs?2(0 - go - ac o
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. X Replacement c. ❑ Replacement of d. E1 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. X Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. seepage Bed b. ❑ Seepage Trench c. ❑ seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQ IRED (Square Feet): PROPOSED (Square Feet) :
Feet O Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank , ® ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume resp!54Ei2i ewage system shown on the attached plans.
Plu ber's Name (Print): MP/MPRSW No.: Business Phone Number:
2Q. loxv< A0 Plum is Addres (Street, C' , State, Zip Code): Name of Designer:
Vlll. SOIL TEST INFORMATION
Certi ' d it Test CST) Name CST #
CST's ADDRE S (Street, C' , State, Zip Code) Phone Number: /
f
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial / D 6 Surcharge Fee V/,/g'~~
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
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; T
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed . .
pUmper whenever necessaryusual•ly•every.2 to•3:"ars;
6. If you have questions concerning. your private sewage syste;n, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815-
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
If. Type of building or use served: It 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;
111. 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 a// septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form-,
GROUNDWATER SURCHARGE
On May 4, 1984, 983; Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the T
result of. over 2,years of steady nego.:atior and public debate. The groundwater bill Groundwater -
included the creation of surcharges (fees) for a numbeir of regulated practices which Wiscor~ in's
can effect groundwater. The surcharge took effect on July 1, 1984, All of t~ e water that buried treasure
is used irf your building is returneq.,tc- the.. groundwater through your soil absorption CC ~ ~
;system or the disposal site uskod byyour holding tank pumper'
The nnon,es . ollected tl'rOUgh these = urcharges are credited ',c the groundwater fund adminis-
tered" by the Department of Natural P.xso ;ices. These funds are used for €nonitoring ground- t
water, g!oundwater contamination in,,estigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03B6)
r
■
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER _t p
V a rr«5 s. n, cle TOWNSHIP I~I c.vrL orc` SEC. T J,:f,_N-R_ /g W
ADDRESS 1Qf,-q ST. CROIX COUNTY, WISCONSIN
SUBDIVISION 6j ~ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
B
al
80
Y ,v v
Y. ,
3
e
/I 010
a
~o W
x
v
S
Q
I
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used Na Iv~ Tpc~,e r Tt~r-
j (~U•~
Elevation of vertical reference point: JDq 0 Proposed slope at site:
~ Xisfi
SEPTIC TANK: Manufacturer: r y Liquid Capacity: / 60 0
Number of rings used: Tank manhole cover elevation: 91,0
Tank Inlet Elevation: 615 Tank Outlet Elevation: 9/1
y
Number of feet from nearest Road: Front,@ Side,O Rear, O /Do ~ feet
From nearest property line Front,0 Side,O Rear, O feet
Number of feet from: well ~.5 building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: la Length: $O Number of Lines:.2 Area Built:
Fill depth to top of pipe:
i
Number of feet from nearest property line: Front, O Side, Rear,O Pt. S
Number of feet from well: 6
Number of feet from building:
(Include distances on plot plan).
e.R .
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number.o feet from well:
Number 0-f d, from building:
Number of feet rom nearest road:
Alarm Manufacturer:
Inspector:
Dated: 4o -L'90- ~ Plumber on job:
License Number : 6 r o2 C9
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 1969 BUREAU OF PLUMBING
KADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Planl.D Number
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DA E.
James Refsnider Rt. 4, New Richmond, WI 54017 0?0
BENCH MARK (Permanent reference pov)l DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST HET. PT. ELEV.
SW SW, Section 3, T30N-R18W, Town of Richmond
N,rr of P ,nnt r- IMP/MPRSVV N... County Sanitary Permit Number:
Cal Powers, Jr. 1563 St. Croix 79203
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIOUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING E:YILDINGI LOCKING COVER
PROVIDEPROVIDED
DYEDYES ❑NO
BEDDING. VENT DI VENT IMTO HIGH WATER NUMBER OF ROAD: PROPERTY JWELLL~~~L . VENT TO FRES H
ALARM FEET FROM f~. LINE i, TY AE AIR INLET
DYES ONO DYES ❑NO NEAREST tj /y{' ✓\l
DOSING CHAMBER:
MANUFACTURER BEDDING ILTIOUID CAPAC ITV PUMP MODEL PUMP: SIPHON MANUFACTIIFtER WARNING LABEL L ING COVER
PROVIDED. PROVIDED.
DYES ❑NO DYES ❑NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF jPHOP1111Y 111111-L BUILDING JVENTTOFIIISII
(DIFFERENCE BETWEEN FEET FROM LINE AIR I"LET
PUMP ON AND OFF) DYES ❑NO NEAREST 30
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH IDIA11F TI I+ IIIATI RIAI AND NANKIN(;
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH IN O.OF ID ISTR PIPE SPACING COVER INSIDE. DIA =PITS L
ID
BED/TRENCH TRENCHES ( ro EHIA PIT DEPTH
DIMENSIONS ~
GHAVF L DEPTH FILL DEPTH UISTIt P ME DISTR. PIPE DISTR. PIPE MATERIAL NO. DI NUMBER OF PROPERTY WELL BUILDING VENT TO FHFSH
BE LOW~PIPS ABD EvEJ-1 F E V INLF r ELEV. END PIPES FEET FROM L \ [f AI~J "tr~
11//t~//3311''~, `T NEAREST------m- a•J 7 60
_ '_Ty\ T
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-
DYES ❑ NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TE%TUHE PEHMANE NT MARKERS MIST HVATI()N WI I I S
DYES ❑NO DYES ❑NO
DEPTH OVEH THENCH BED DEPTH OVER TRENCH. BED DEPTH OF TOPSOIL SD SEF UFD MU LCHE D
CENTER EDGES
YES ❑NO DYES ❑NO DYES E] NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACING (;RAVEL DE PT H BF LOW PIPE F ILL DEPT H ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR jU:STEI PIE DISTVtIHOTI()N PIPI MATE HIAI & MARKIN(,
E4EVATION AND ELEVELEVDIAELEVPIPES DA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LV COVER MATERIAL VEHTTCAI I. IF T CORHFSPONOS TO APPROVID
PLANS
DYES ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUILDING.
FEET FROM LI"E'
DYES ❑NO DYES ❑NO NEAREST
Sketch System on Retai 'n county file for audit.
Reverse Side.
SIGNATURE TITLE
DILHRSBD6710(R.01/82)°~~
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 _-,Skd_ ~~>u) , Section T 3 oN-R~ W
Township
Mailing Address 7 y
Address of Site
Subdivision Name
i®Gi -~L1 Orir~
Lot Number` 3
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
l'Are all corners and lot lines identifiable? Yes No
-Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number SSI 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
I (We) cvLti.jy that att statements on this 6atcm ahe tAue to the but a6 my (auto)
knowledge; that 1 (we) am (ahe) the ownetc(.a) og the pttopeAty denscA bed in this
in6atunation 6oACm, by v.ihtue o6 a wa4 anty deed tcecottded in the 046ice o6 the
County RegisteA o6 Deeda" Document No. and that I (We) pttesent2y
awn the p>zapazed site 6atc the ewage ".s
pays z ys em • (o& I (we) have obtained an
ea5ement, to nun with the above de3cAibed ptopenty, Gott the con6tAucti,on ob .said
dy6tem, and the same has been duty necattded in the 046ice o6 the C Registert a6
Deed6, a.3 Document No.
t \ 1
SI TURE OF OWNER SIGNATURE OF CO-OWNS (I APPLICABLE)
DAT IGNED DATE SIGNED
H
- z
cn
• H
9
STC - 105 C"
9
f SEPTIC TANK MAINTENANCE AGREEMENT ry_q
St. Croix County z
OWNER/BUYER /
ROUTE/BOX N ER Fire Number } l~
.CITY/`STATE ZIP 'iJ aI
PROPERTY LOCATION:-14, 5;,,) ' Section , T 310 N, R W, 'q~_
Town of , St. Croix County,
Subdivision hS2Rti. Lot number 3
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.
0
I/WE, the undersigned, have read the above requirements and agree z
to maintain 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 J 9 C
S
43-
St. Croix County Zoning Office
P. 0. Box 984-
H ammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF SAFETY & BUILDINGS
DUSTRY, IN
REPORT ON SOIL BORINGS AND
LABOR AND P.O. BOX 7969
PERCOLATION TESTS (115) DIVISION
HUMAN RELATIONS
(H63.090) & Chapter 145.045) MADISON, WI 53707
LOCA ION: SECTION: TOW IP/M+P•A-LITY: LOT NO.: BLK. O.rS %B~ VISION NA
3 IT3D H/R r (o
COUNTY: OW R'S/BUYER'S NAME: MAILI GA RES .
USE I
NO. BEDRMS.: COMMERCIA DESCRIPTION: DATES OBSERVATIONS MADE
Residence ❑New Replace PROFILE DESCRIPTIONS: PER OLATION TESTS:
RATING: S= Site suitable for system U= 6Site unsuitable for system
CONVENTIONAL: MOUND: IN-GND-PRESSURE: SYSTE -IN-FILLHO DING ANK: RECOMMENDED SYSTE9A:'optional)
C]S DU fz7S ❑U S ❑U OS JU JU DS ~U /
If Percolation Tests are NOT requir DESI N RATE:
under s.H63.09(5►(b1, indicate: If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH In, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
B-
B
B-
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES
NUMBER •~i+fcS AFTERSWELLING INTERVAL-MIN. RATE MINUTES
PERT 1 PERI D2 PER O PER INCH
P- rs 1
P-
P
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
V
SYSTEM ELEVATION
-
A
E
E
E
I I~~
G F
-
Sur ~A- Ae_
t
E
i t
€ ~ t
f
. E
7
E E
I I ti
he undersigned, hereby certify that the soil tests reported on this form were made by me in acc rd with the p ocedures and methods specified in the Wisc Ain
ministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
(pri
TESTS WERE COMPLETED ON:
SS:
CE I!N NUM *PONE NUMBER(optional):
C T E
1. 3 UTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
BD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING , ; . 115 - SBD - 6395 a
To he a cc -i ' " (i -agate sail test. Yolar report ml-
;
Co ryl P
2. Ti > it~r iratr tether this is a residence or commercial project;
3, RA - rcial use planned;
'S SUITABLE "9 r"ING TANK ONLY IF ALL
completing the t plan;
vatic n: 3 sa A
7,
e' )p-
in .".t` ,.:ox;
i'
W i`ilT Tl"'i
1. ~1 ` `
-VIA l _ -')I l.. TESTERS
ex tea res
l r
rs
rrved s
ls ian
is
*sl
C
P1
ri
Paint
TOW,
E in c » i ° it may request A
for the private
n order to NA
r ac r1.
A
~~STR
Did yR-
PAGE OF
CrOSS Se-cjlun Ot A Ser7 System
Fresh Air Inlets And Observation Pipe
, ,~1 +e,h,aJ, ii)sr ^ -
L..T- Approved Vont Cop
5 61' Minimum 12' Above
Final Grade
i
20- 42' Above Pipe _ 4" Cost Iron
To Final Grode vent Pipe
Me►eA Mar Or Synthetk Covering
Mln. 2' Aggregate
Over Plpe
Oluribution
Pipe 0 0 0 0 - Tee
6" Aggregate
Beneath Plpe 0 Perforated Pipe 8e10W
_-r 0 Coupling Terminating At
Bottom Of System
i
7
! P~VPOSeD Ina' 9rhA i
SOIL FILL
DISTKIBUTIOF,7 PIPE
APPROVED S4ETIC COVER
"``-MATER14 OR 9" OF STRAW
Z"oFt%Grj ErjATE• OR MAKSN NAy
0F2i/Z AGGREGATE
ELEV. oFg-k b
/
- 1
DIST'RiF5UTI0IJ PIPE TO BE AT LEAST IIJCHES BELOW ORIGIAIAL GRADE
AMU AT LEAST20 IIJCHES BUT AIO MORE THAI) 42 INCHES BELOW FIfUAL GRADE
MAXIMUM ®F-QTH OF EXCAVATIOIJ) FROM ORI&YdAL 6KA0€ WILL BE -L/.~ IIJCHES
PUKiPWIM ®F-Pr" OF EXCAVATION FROM 00KI4INAL 694o€ WILL. BE INCHES
SIGUED: I
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DATE: - Af /5 C .
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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP _ SEC._ T _30_N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
~"7T q)
SUBDIVISION LOT 3 LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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75
Or
e.
o/
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used Elevation of vertical,reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer:.'&Ld yg Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front, Side,0 Rear, 0 feet
From nearest property line Front,0 Side 1P Rear, O feet
Number of feet from: well 4building: /e
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE. REVERSE STPE.
V
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: I- - Length: Number of Lines: Area Built:
-L
Fill depth tGGoo top of pipe:__ W,
Number of feet from nearest property line: Front, O Side , Rear,j Ft
i t~~
Number of feet from well:
Number of feet from building: ~'Y
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: ~zS Plumber on job: /Jt.J r9m)e,~S~
License Number: e 3
3/84:mj,
DEPARTMEN3 OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
,LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707 '
❑CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number
IIf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER! JADDRESS OF PERMIT HOLDER: INSPECTION DATE.
BENCH MARK (Permanent reference pomO DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: IMP/MPRSW No.' County Sanitary Permit Number:
SEPTIC TANK/HOLDING TANK:
MANUFACTURER . LIQUID CAPACITY. TANK INLET ELEV.. TANK OUT LE? ELE V.. WARNING LABEL LOCKING COVER
~11 PROVIDED PROVIDED
V EYES ENO OYES ENO
BEDDING: VENT DIA.: VENT MAT I HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING: VENT TO FRESH
LARM F ET FROM LINE. AIR INLET.
EYES ENO YES REST _
DOSING CHAMBER:
MANUFACTURER 71YN-GLIQUID CA n(:IT MODEL PUMP:SIPHON MANUF ACTIREH WARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES ENO OYES ENO EYES ENO
GALLONS PER CYCLE: Pu ANOCONTRO soPERATONAL - - NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ENO ]NEAREST->
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing nAM19F TEE 111ATIHInI AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH JLENGTH NOF DPIPE SPACING COVER INSIDE DIA -PITS LIQUID
_ THENCHES M 21A L' PIT DEPTH:
DIMENSIONS I 2_- 1)
lR.' VFL OLI'TH FI LL DEPTH UIST 12 PIPE DISTH PIPE DISTR. PIPE MATERIAL NDDIST110 NUMBER OF PHOPE WELL BUILDING. VENT TO FRESH
BELOW PI C ABOVE C VER E EV IN.1,11f ELEV END PIPES FEET FROM LINE AIR INLET:
t ! NEAREST-
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
EYES NO
SOIL COVER TEXTURE E iMANI NT MARKE HS OBSERVATION WELLS
I //f _ ENO El YES ENO
DEPTH OVER TRENCH BED DEPTH OVFR TRENCH HE.D DEPTH OF TOPSOIL DFO MULCHED
CENTER EDGES
EY S. ENO rUFD DYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF LATEHAL SPACING GHAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH ID, STR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.' ELEV.. DIA ELEV. PIPES DIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LV J COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
EYES ENO EYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVAT w. S NUMBER OF PROPERTY WELL: JBUILDING:
FEET FROM LINE.
O YES ❑ NO ES ❑ NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
f
r SIGNATURE. TITLE'
ft, .t ~r f f r.
DILHR SBD 6710 (R. 01/82)
5ILHt~ SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8'/z x 11 inches in size.
-See reverse side for instructions for completing this application.
PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
'/4 '/4, S T N, R E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER 77 CITY : NEAREST ROAD, LAKE OR LANDMARK
O VILLAGE :
El TOWN OR
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. ❑ New b. E1 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. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ Seepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet ❑ Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ 1:1
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) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST #
CST's ADDRESS (Street, City, State, Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee
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
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:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
Il. Type of building or use served: If public is checked, indicate type of use (i e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two farnily dwelling;
Ill. 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'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more 1
commonly known as the groundwater protection law. This change in statutes was the ,
result of over 2 years of steady negotiation and public deviate. The groundwater bill :,roundwater
included the creation of surcharges (fees) for a number of regulated practices which ,
Wiscorr~; s
can effect groundwat~ r. The s1.ircharce to,-,)k effect on Juiy 1, 1984. All «f the water that buried tr~a.s+_ire
is used ir! your building is returned to the groundwater through your soil absorption
system or the disposal site used by y=our holding tank pun-:per.
The riSonies c:oIlecte-c, through these surc~!arges are c edi'ed to the g:oun iwa'or f,.nd adminis
tereci by t )e Department of Natural R source. These funz°s are used nor or tnr rg grour d-
s.
wate°, groundwater ronta'lllncttlOn In ?St~jati')nS ',n[ Str.'lda"dS irG.Jnd1s'+atet', --Y _7
it's worth protecting.
SEID-6398 (F;.03l86)
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PAGE OF
Cross- Sec~lon O~ A ben SySter,
Fresh Air InIels And Observation Pipe
Approved Vent Cap
Minimum " A'ove
find Gr12ods
20- e2" Above Pipe _ 4" Coat Iron
o final Grade Vent Pips
sseren May Or Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution
Pipe o o o o Tee
I 6" Aggregate
Beneath Pipe ° Pertoretea Pipe BNow
rCOWINO Terminating At
lottom of system
I
FruPoscD ~I~aI `9rA~1{ ~ F110,
50- 011",
SOIL FILL
DISTRIBUTIOf.1 PIPE
APPROVED SI4N'PETIC COVER
° ""'-MATERIAL- OR 9" OF STRAW
OF46GREGAI tjARSI.1 IAA1
r ° (o OF 1g-2~~~ ^.CGREGINTE
'LLEV.OF FEET_..~.
DISTRI5UTIOAI PIPWr' TO BE LEA5T ~uCHE:r BELOW ORIGINAL GRADE'
AQE) AT LEASTP-0 dMCHES BCC T 1,10 MORE i Hr+,r i x42 IIACNES BELOW I'MAL GRADF:
MAXIMUM DEQtH OF EXe-AVAT160 FKOM OKIGLNgL 6RADE WILL BE L/~ INCHES
MINIMUM 9F-f Tli OF EXCAVATION FROM OIKfGIWAL (jR49E WILL. BE S INCHES
i
SIGUED:
got
LICEMSE DUMBER:
t
DATE
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DEPARTM•ENrOF REPORT ON SOIL BORINGS AND SAFETY & IWILDIW;S
IN~~USTR-Y DIVISION
LABOR AN-D ' PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON WI 53707
-
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOW IP/M4J44"tPALITY: OT NO.:BLK. O.: SUB IVISION NA
3 / - H/R to
COUNTY: OW 'S/BUYER'S NAME: MAIL G A RES 'I
USE DATES OBSERVATIONS MADE
NO. BEDRMB.: COMMERCIA4 DESCRI TION: PROFILEDESCRIPTIONS: 1PERCOLATION TESTS:
~Res~dence ~ ❑ New J~J Replace
RATING: S= Site suitable for system U= Site unsuitable fors stem
ONV NTIONAL: MOUND: ~IN-GROUND-PRESSURE: SYSTE -A"' HO DING COMMENDED SYSTE :(optional)
ZS CCU ZS EA _®S C)U EIS EIS Al CCU
nDE'S71N R~~TE: If Percolation Tests are NOT re quire If any potion of the tested area is in the
under s.1463.09(5)(b), indicate. Floodpl, in, indicate Floodplain elevation:
!l" PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH FN, ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B- _ D - ~st r
B- ~
B - - 3.
B-
PERCOLATION TESTS
TEST -DEPTH WATER IN HOLE TEST I IME DROP I WATER LEVE -INCH S RATE M111INUTES
NUMBER #NGHILS AFTERSWELLING INTERVAL-MIN. _
P t P RI D 2 PER INCH
/
P It
P
AAO)JIA Z f
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensiu.is of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference 1,oints and shoe, their location or the p!et plan. Show the surfaze elevation at. all borings rind the direction and percent
of land slope.
SYSTEM ELEVATION _Sw
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fil
15 3
A9U54
9A 4 31
I, the undersigned, hereby certify that the soil tests reported on this form were made by mein acc rd with the procedures and methods specified in the Wis sin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAM '(pri TESTS WERE COMPLETED ON:
A D SS: CERTIFICATION NUM P ONE NUMBER (optional):
z I- / 5 i S-ZLIS7
C T N RE
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER
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