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HomeMy WebLinkAbout036-1048-70-000 ti 0 to m CD T in c' T B rr - N O - D' O rn ~ 0 S Z O G7 ~ I m n w o z o c ~ o v w rn • ED ( <D W N 3 O_ +*D W N 7 O ` C m a m a: CD y cn A j ^ N CL C) m C~ O N m r V 00 W ` 1 C. C! tD N 7 N ID i W O ~O 0) C ro ~p n 7 Cf O 7 W O 3 o d O Z Z O C D7 c v c v O i~, !Y to C D e~ F to D a CD U) 5 in CL CL o W w W oo l M CD C CL 0 O N ' f00 a N O N I L w :r nr z z co r- CA O cn O rn rn m fA o c I Z Z 3 ~ lr I T v' "wl• Z 0 0 0 0 0 0 !!!gill l 3 (D 3 vi vi vi 3 m v I o m m e vi co CA m m 0 ~ a I a' y ni I o G) 1 G) 90 N !D O O a I a > > N z J J l~ D co ? D co m O , O "VA ~ • 0 CD CD y co 'a CO) m 0) cc a ~ cl) m c c I a a 3 3 V] H m m -I to O rt 0 C o A Z n N N Ch 7 N .a .-p ro C. n ' b 0 (D rt N 1-4 H fA W O rt n rrt b o x z W W a CL L C 3 3 Z Z _ z U.) CD CD 'ln W W A (D oai a m c n H d cca d o N ~ n Ioo 3 o=i c I m 'm c rr o o o a N o a A3 m u, F- *z I 01 co m N fD rn a CD tSi y a ~o w CD a coo r H H CD CO a o w t`J O co y ED 0) 17M ON rn' n m a ~m a v in y a V cn rt n 00 °a rt w r cm °o Oo I- N O v O j CD m ao °+a ~O rfl0 ° CD O g o `A CD d 00 d Form - STC - 104 1 AS BUILT SANITARY SYSTEM REPORT OWNER ~IC TOWNSHIP 9-YV ~-~'7? SEC. c2o T- N-R 7 W ADDRESS ST. CROIX COUNTY, WISCONSIN V-pi SUBDIVISION LOT 4!: LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM U.,Sfa ~L° 71 -7 -2! r 9 S~ -o av~t INDICATE ORTH ARROW BENCHMARK: Describe the vertical reference point used N Elevation of vertical reference point: 1&0 ' Proposed slope at site: 3 6 SEPTIC TANK: Manufacturer: E(~ S Liquid Capacity: Number of rings used: 1 Tank manhole cover elevation: Tank Inlet Elevation Z- Tank Outlet Elevation: Number of feet from nearest Road: Front, Side 0 Rear, O feet From nearest property line Front,O Side, Rear, 0 feet Number of feet from: well 004- , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE t PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: ump/Siphon Manufacturer: Pump Size ElZfacturer: Bottom of tank elevation: Pun: Gallons per cycle: AlAlarm Switch Type: Nuest property line: Fro nt, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM f_ Bed: Trench: Width: S Lenth: ' Number of Lines: Area Built: '745kV Fill depth to top of pipe: hZ 0 Number of feet from nearest property line: Front, O Side, Rear,O Number of feet from well: 1F}Q~~ Number of feet from building: 7 - (Include distances on plot plan). SEEPAGE PIT Size: tuber of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Bui ,Has eithe a drop box O or distribution box O been used on any of the above soil absorb on sytems? (Check one). HOL NG TANK Manufactur Capacity: Number f ring Elev tion of s used: Elevation of bottom of tank: inlet: N er of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: e Plumber on job: License Number: _ & S 3 -RS 3/84:mj EPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION -O..BOX 7969 BUREAU OF PLUMBING ADISON. WI 53707- XXONVENTIONAL ❑ALTERNATIVE $talePlan l.D.NurMwi 111 ❑ Holding Tank El In-Ground Pressure 1:1 Mound asvpneAl FAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE A;yy Nick Golz 1161_2 Dayton Ave. St. Paul-Park MN FENCH MARK (Permanent rtf,,e ePorntl DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST HEf PT. ELEV SE SW Section 20, T31N-R17W, Town of Stanton am. nl PWrulrtr. IMP/MPRSW No.. Countv Sannarv P-.1 Numher: Gar Steel 3254 St. Croix 83835 EPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TAN INLETELEV. TANK OUTLET ELEV WARNING LABEL LOCKING COVE" O _ 6 7 PROVIDED PROVIDED !'~'/Yf 17 v /Vl 7 OYES ❑NO ❑YES ftNO EODING. VENT DIA. VENT MATL t/1GN WA EH NUMBER OF ROAD: PROPERTY WELL [UILDING VENT TO FRESH / ALA"h1 FEET FROM 0.0 LIN~,( / IA.. IN~E~ ❑YES t~vo I 44 ~1 ❑YES NO NEAREST t/ V S LOSING CHA BER: IMANUF ACTUREH BEDDING LIQUID CAPACITY PUhIV MODEL IPU IPHpN MAN F CTUItF" ]WARNIN(;LABEL LOCKING COVER PROVIDED PROVIDED ❑YES ❑NO DYES LINO ❑YES [JNO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATION N BER OF PH(IPF II 1y IWI Lt IIIIIIIIIING IVINI TOfIUMI (DIFFERENCE BETWEEN FE T FROM LINf AIR INt II PUMP ON AND OFF) ❑YES O N REST-> Ih OIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FO E IF int [iArtil n 11 I%IATI141AI AND MAItKIN1, 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 JWID~TH LENGTH INO OF UISIR PIPF~SVA(~ ANI COV E INtiIOf 1114 sVI1S I IUUII) iNENC FS MAT IAL PIT ()FPIH DIMENSIONS E`Vw hHA VFL UE VF t fILLU PT11 UIS 111'11'1 UISIH PIPF DISTR. PIPE MATERIAL NO UIS NUMBER OF PHUPEHTV WLLL HUILUING VA 111111!`.0 Hf LOW US AH ECO`taH IIFV INlft ELEV ENU PIPES FEET FROM ,LIEyE~) o\) L ~^f A l~ trJL ( NEAREST-► 1 T L ~E OUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it . ON REVERSE SIDE. SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. OIL COVER TFxIIIRF VF Iki ANI NI MAHKI IES 0851 I4VAf111N WI 11 S ❑YES ❑NO _ CJ YES LINO UFPTI)OVER I"[N(:O NCU Df Vtflovt H IRE NCH BE II Nf VTH OF IUV$UIL SUUUfO SFE UFO T1111ijHlU CENiEH EDGES ❑YES ONO CIYES NO ❑YES LINO EPRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO. OF LIEHAL SPA(:IN(i riHA VfL Uf PT11 HIlOW PII'I tILL OF VIII AHrIVf f.UVI" TRENCHES DIMENSIONS_ MANIF Ot0 PUMP MANIFOLD UISTR. PIPE MAN11OLDMA EIIIAL N(1111ti I1f I)I$IH Pip IIIti IItl Hlllln VIII h1-A7I1IAI &h)AIIKINI, ELEVATION AND ELEV ELEV DIA ELEV. 1'IPFS UTA DISTRIBUTION INFORMATION HOLE SIIf RULE SPACING UItILIEU CU"Rf CITY CUVFR MATEHIAL vE I11 It At I It T 00100 SPONUS TO APPI44 IV1 I) Pt ANS ❑YES ❑NO CJ YES ❑NO COMMENTS: PERMANENT MARKER OBSERVATION WEL N LS UMBER OF P"OPERTV WELL BUILDING FEET FROM LINE c_ ,~,}r YES ❑NO ❑YES ❑NO NEAREST _ Y ~10 ~•31 ~ ~ofl ,33 ap . ~ 5.0 Sketch System on 7 ^ j Z. ain in county file for audit. Reverse Side. , SIGN I TITLE DILHR SBD 6710 (R. 01/82) ~ 0 SANITARY PERMIT APPLICATION COUNTY/ DILHR In accord with ILHR 83.05, Wis. Adm. Code w ` a - STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on not less than d paper STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER PROPERTY LOCATION i Z_ '/4 S 0%, S C7 T el N, R 7 (or) W PROPERTY OWNER'S MAILI G ADDRESS LOT NU BER BLOCK NUM ER SUBDIVISION AME ITY STATE ZIP CODE PHONE NUMBER CI Y N NEARESNROA/D,VdLAKE OR LANDMARK e E1 VILLAGE : 11. TYPE OF BUILDING OR USE SE VED: j , Am. 03(0 lQ e --©c Number of Bedrooms if 1 or 2 Family OR LJtic (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. 674. New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. E1 Repair of an System System Septic Tank Only / an Existing System Exi ing System 2. 6 A Sanitary Permit was previously issued. Permit # Date Issued *7-3 495 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.,g-ticonventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. E1 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.-.See a e 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): d oa od Feet Private ❑ Joint ❑ Public CAPACITY VI. TANK Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank oO0 1 U) Q-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): Plum 's Signature: (No amps) 4AP/MPRSW No.: Business Phone Number: G Z 7/5 -6 ZOo Plumber's A dress (Stree , City, St te, Zip eName of Designer: c1018 oeshhIrc- Vill. SOIL TEST INFORMATION Certif' Soil Tester (CST) Name CST # P_ Z 7~e CST's DRESS (S eet, City, State, Zip Code) Phone Number: -7 z - IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Grou dwater jae Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Sur arge Fee Adverse Determination ~i © 02.5 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; 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 privat~i sewage syste ; ,.ontact.ytour 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 nar se and mailing address Provide the legal description where the system is to be, i nstaftd; II. Typer-of building or use -served: If public is checked, indicate type of use ;i.e. 10 unit apartment, 36 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; 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; Vill. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or`other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984; 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater" protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground-water - included the creation of surcharges (fees) for a number of regulated practices which WiSComin's can effect groundwater. The surcharge took effec` on July 1, 1984. All of the water that buried tteasLtre~) I , is used in. your building is returned tc the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. The monies coliected through the-:se srchi areas are credited to the groundwater fund adminis- tered by the Department of Natural R )sources, These funds are used for r-non Loring gruur',d- t water, gnoundwater contamination ire4estigations and establishment of standards. Cro,jndwate'I., - it's worth protecting. SBD-6398 (R.03/86) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN-RELATIONS 1 / MADISON, WI 53707 • (H63.090) & Chapter 145.045) LOCATION:S SECTION:T R TOWNSHIP/.N%# lae~ i Y LOT NO.: BLK. NO.: SUB~DI/VI ION NAME: COUNTY: OWNER"WtB FER+B+ LAME: MAILING ADDRESS: I- Z- ~iZ4 rK USE 1 ~ Y► NO, BEDRMS,: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS ADE PROFILE DESCRIPTIONS: ER OLATI TESTS: L;s :3 d I 0= Residenceew ❑Replace y/ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURET Y STEM-IN-FILL HOLDING TANK: RECOMMEN E SYSTEM: (optional) ~,S DU DU DU CJS/I ❑S RU ra F rcolation Tests are NOT required DESIGN RATE: If an \ y portion of the tested area is in the } r s.H63.09(5)(b), indicate: ~J Floodplain, indicate Floodplain elevation: f~ Igryg PROFILE DESCRIPTIONS z~g t Z BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTM-", ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 57 rovj to _y. 3.1 1 Cl ? 33 1 3 ' 7 B- 3 9 3 A)o 6.~. ;1. =5~ s. .c . o s 06 Otj '7 ~ O 33 3 IV I 97 B- I a PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 4PZIT 5 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER D PER INCH P_ 1 3 P_ z 3 4x v 30 / o P- 3 m o 30 '710 10 3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION F yf[Y{'~_ 3 t I i i j t ( f a ~ 4 € I } 4 E l.. G E `N r t f ~ E F b _W I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRE ~ 7- 1 8 -s's CERTIFICATION NUMBER: PHONE NUMBER(optional): 4"nz - 01- 1, 7_Z98 -Z -b CST SIG TU E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - JCTIONS FOR COP""'@ ---SING F°' E 11 -SAC} - 6395 I r accurate soil to 1. Co nrir>n; 2. Tl C, Irly i pis is a residence c project; 3. M edroorns ' planned; 4, ist systern, " ONLY I ALL , ^ t`ng aoxe ~q IITABL 0 .ULED Chi ~ AIL `ot . PL 7M id are PEA. u reolation test e rnp- t 3 A ple •°j t~, - . -priate box; _ ur Current ~ istribute as E dTiI THE r VITHIN 3Q DAYS C - "A $ I NS F CF T&. res co r mad rs - Es T the pi i ~4t1~ C } ~l fro rrti' 06 44-kZu0-K 5 r lp` r /~G~i2 S Gc~ 3~ k ST. CROIX COUNTY WISCONSIN ZONING OFFICE 796-2239 (HAMMOND) { 425-8383 (RIVER FALLS) HAMMOND, WI 54015 August 15, 1986 Ms. Carolyn Haag State of Wisconsin, DILHR Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Carolyn: Permit #83835, issued today to Nick Golz is replacing permit 464931, issued 7-3-85. The pert is new, and the system location has been changed. Attached please find permit#64931. Should you have any questions regarding this, please feel free to contact this office. Sincerely, 4)~M Mary J. Jenkins, Secretary St. Croix County Zoning Office Attachment r M Z O -0 O C0,02 Cn 0 ~ c ~ o0 z z 4. M O M OD :10 M M 0 _ r N O 1 x COOD M - cC-n m m r m v N Now ~ p. 0 C 1 r ~ O - n r m D C7 C) ° m O O N z M cc: x D U ~ -n c g n z 0 O "9W r m o ~ z Cn - zz n O O cn m z Z ~ :10 C rn , N Z Cm z7 .m Ny;A SO fa fll°c m3 od MoD n 7 .m 0 ~~37 ~v N~ S r rTl o 7 N O O M W t0 n W Q L H N ~ p oiS O< ~c cz. , m 3m O P. om M 0. m M C.0, v M 7 N N< N S N y~ 7 w < S O 7 0 0< 7 d (71 O d T ~fD =r ^3 3 3 < Gov 3 ~ n d M d o v 3 n dc vn> 3 fTl L O Z > 17 am z CL 140, o < O o D =mom a 07 m m~0 3M. C m ~ d ~ N ~o m p 3 3c °y° vi CY) v < v~ D d 3 0' < o' O CD N N H W H M M V J M co m~ 3 0 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 796'9 BUREAU OF PLUMBING MA[YISON, WI 53707 Jdd)CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: • (lf assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION DATE: Nick Golz 1612 Dayton Avenue, St. Paul. Park, MN ` BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. EV.: CST R . ELEV. SE SW, Section 20, T31N-R17W, Town of Stanton Name of Plumber: MP/MPRSW No. County: S ita er Gary L. Steel 3254 St. Croix SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED PROVIDED ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL. HIGH WATER {NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. FEET FROM LINE. AIR INLET: ❑YES ❑NO ❑YES ❑NO NEARE_ST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: 77ND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING.( (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST I SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing r,rH JDIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH JNIDISTR PIPE SPACING COVER INSIDE DIA #PITS LIQUID TRENCHES. MATERIAL' PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER. ELEV. INLET ELEV. END. PIPES: FEET FROM LINE: AIR INLET: NEARESTs 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- ❑ YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/6E. DEPTH OVER TRENCHiBED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER. EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV.. DIA.. ELEV.: PIPES. CIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: FNEAPE BER OF PROPERTY WELL: BUILDING: FROM LINE: ❑YES ❑NO ❑YES ❑NO ST 3110 Sketc h System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710 (R. 01/82) Wisconsin APPLICATION FOR SANITARY PERMIT ((PLB67) COUNTY i~~ oecRRTmenTOF UNIFORM SANITARY PERMIT # - I..USTRIIR...... rnRn.1RTIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERT OWNER MAILING ADD i z PROPERTY LOCATION 61 : ~C 1 /46 Q1 /4, S 20 , T3 N, R E (or) W TOE WN OF: LOT NUMBER BLOCK NUMBER ISUBDIVISION NAME NEARES ROAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER 12 A) A 1! A/jq TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: `New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: WjA.F 0- IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): "F ~Z 0 Q ~d Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installati f the private sewage system shown on the attached plans. Name Plumber (Print): Signature: _flWMMPRSW No.: Phone Number: 3-;5 Plumber's Addr ss: CC Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: 0,3 Date: ❑ Disapproved I? Z_ ❑ Owner Given Initial " 1~, 6414t), J,19~lwl p Approved Adverse Determination 1;v Reason for Disapproval: Alternate course(s) of Action Available: 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: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in 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.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 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 who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 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. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) 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. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. • APPLICATION FOR SANITARY PERMIT S T C - 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/contractql~,("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 0/2f~ Location of Property S 1, Section -20 T ~ N - R )7 W Township 5 Mailing Address Z r4J14- 4 rS 4 1 a&4: kl 1 /n Y7 Subdivision Name Lot Number Previous Owner of Property hiSC~ 0 W L Total Size of Parcel s6 ty~ k S. . Date Parcel was Created 'V- Z C,L - S Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number Z Z as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE Or' 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) cents jy that aU atatemenfi6 on thi,6 Jonm ahe t&ue to the best of my (oLVL) hnow.bedge; that 1 (we) am (axe). the owneAla) o~ the pnopehty debch.i.bed in .thi,6 in6o4mati,on ;jonm, by vi tue o6 a wannanty deed neconded in the 066ice of the County Regi6'ten o6 Deeds ass Document No. hlo/ (,,a o ; and that I (we) pu/sentey own the pnoopobed site Jon the 6ewage poa ,system (on I (we) have obtained an tad emen t, to nun with the above dea cubed pno peAt y, jon the comtnucti.on o6 aaid 6y6tem, and the aame ha.6 been duty neco.,Lded in the Oj6ice oS the County Register of Deeda, ab Document No. j V J,4y -7 ;EZ SIGNA URE OF OWN SIGNATURE F C ER (IF PLICABLE) n DATE SIGNED DATE SIGNED J H z y ' a STC - 105 r" . r a SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County z d a l H OWNER/B'"ER ROUTE/BOX NUMBER/ I Z f ),q~, ,8t~~ Fire Number CITY/STATE ~ AA T I n yl ZIP PROPERTY LOCATION: c'~6,- 14, &ID 14, Section a D , T01 N, RZ_W, Town of 15 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 put into If 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 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 St. Croix County Zoning Office P.O. Box 98' Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. I U t j- .0 O C (D 75 (D 4) L- a to 7 J" + V fA E o 0 4? W C a O U) 'C 0 0-0 o0a~a) ; o- W "Z;92 0.0 0 v E c to cc N 0 " a- 0 C -ii C_ cm m ~ . a ~ 7- U >N ~ ~~0 1 O c~ = 0 G u a ~ +1 G V o _ C 0 0N a ' 303: =-0 oyE c U) CMD U) 0) 'a O N O L t C Cr. C y N O - w ca o Q 0 010 O 4) U) L- 4) (a W6 cm 0 Z cn 0 (D (D 0 a ~ o U) CL r o 4) ~ 0 co o) CL :3 0 0) 75 (D °M a°'ivca a0cc_' a c m`'a or00 ) o ~ ~ o L (A C O O O~ 0 0 0 3 C p p) Z C N C>1 p E 0 C L ` 0 O O w O m ~ o o Ch 0) Of i V O '0 E 0 (1~ Y L C O rt.. Vt o I- CM C 1 J ~¢4p U) O o L. o O~ .~J 7 v 0 ca 0 3~ c a)c0). Oco 00.0 - 0 3 c x- a in 3 m N o N 0 c ~t C O 0 0 C a o O 0 c Y N M O= 7 O C a OZv! ~ (b ca w o 0 Q ` a C N V U Y E 'a O C N cm o N N A OEcm(At=nwc(o F- 3. m C ~ IX y D DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AM PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN' RELATIONS \ / MADISON, WI 53707 • (H63.090) & Chapter 145.045) LQ AT,ION: SECTION: TOWNSH P/%+H#*e PALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: c '/4 '/4 20 /Tj/ N/R/A(or)W - y COUNT : OWNER'SIBUYER`S NAME: MAILING ADDRESS: USE DATES OBSERVAT ONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: , 42q(ew ❑ Replace I ~ Cs S ~ --3 esidence pv I / RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) EMS ❑U ❑S ❑S U ~,S ❑U S ❑U If Percolation Tests are NOT required DESIGN RATE: [Floodplain, any portion of the tested area is in the under s.H63.09(5)(b), indicate: indicate Floodplain elevation: A ~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER i EpT*4:3 ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 3 7 z 9z, S1 1 "0 , on 4$ 7$ 0 2 /0139 R3 r B- t 3 ~3 10p~ ~0t~~ > 33 j 1.1 _7n.~ll. 7 Z B- Q~~~~ylq(` PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER +NC19E+S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- co 30 P- 2- 3 A) 3 ~0 'B 3 P- 3 AJO _3o z 3 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. LAID CW 4'y Un &L n~ -t-/ SYSTEM ELEVATION p-_Q o~ , 739 E r L i E $ r 40 ,y Pj / cJ r _ ...E ~ _ s , z o E E t , F- E - - - E i 3 f E t ; E E E ~ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: + ADDRE CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNA E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER - L , INSTRUCTIONS FOR COMPL_-:T .-C -.M 115 - SBD - . , "fir, i,. a c~n niptr anti eirnte cnil text, your repc ` r this is ice + 4, TANK ONLY IF ALL 67. P+ , - ing the ( 3t - 7. 0. t[ara tes r t riate box; _ED WITH THE r 4 30 DAY ""IONS FOR tr, °""'"L TESTERS cot) } gr sit Si y T S, D r( J i~ tt) s z v ~3~ti a ~2 l 7A) • E t~ LO /l U,' 60 g~~ 220 ~ I~ 1141 i I ~ ~ i ~1~y0 L Psr `C 13,s 1.2 PF d.2 7.2 9s ~8 /hp~s~3z s-f o c o PD A ~ d m ` 1 I 3 ~ U) O O A O O `C• n O N W 3 0 w N ►"i C. 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