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' Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ey,,5 isiI ~J~tWFf4g, ~ A16, ~Y'~dtr1 SEC. 12-- T IL_N-R~W
ADDRESS
ST. CROIX COUNTY, WISCONSIN
SUBDIVISION A) LOT A)l 4- LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILIiR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f7
f
0
i
S3 `
Flo ~ s
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: / !Ad~
-94" Proposed slope at site: ~
SEPTIC TANK: Manufacturer: W `Liquid Capacity: z. ~ w- 1
Number of rings used: y Tank manhole cover elevation:
C7 g
Tank Inlet Elevation: Tank Outlet Elevation: /Q
Number of feet from nearest Road: Front, &Side 0 Rear, O feet
From nearest property line Front,0 Side,RRear, O f feet
Number of feet from: well j building: ~a I
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
RRR RP.URRRP RTnV
•
PUMP CHAMBER
Manufacturer: Liquid C city:
Pump Model: Pump/Sipho nufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elev on: Gallons per cycle:
Alarm Manufac er: Alarm Switch Type:
Number feet from nearest property line: Front, O Side, a Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM /
V
Bed: Trench:
Width:j _ Length:11hd to Number of Lines: Z Area Built: c
Fill depth to top of pipe: 22 6
Number of feet from nearest property line: Front, O Side Rear,0 ift
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Nu er of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either drop box O or distribution box O been used on any of the above soil
absorbti sytems? (Check one).
HOLD G TANK
Manufacturer: Capacity:
Number of rings sed: Elevation of bottom of tank:
Elevation o inlet:
Number feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
fp Plumber on job:
Dated :
License Number : -
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR &.HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
Mit,DISON, WI 53707
T CONVENTIONAL ❑ALTERNATIVE State Plan LD.Numbec
assigned)
El Holding Tank ❑ In-Ground Pressure El Mound r
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE:
Marshall Boumeester Star Prairie, WI 54026 O 46
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELEV
NW NE, Section 12, T31N-R18W, Town of Star Prairie
Name of Plumber-. MP/MPRSW No. Counry Sanitary Permit Number
Gary Steel 3254 St. Croix 79171
SEPTIC TANK/HOLDING TANK: f
MANUFACTURER. LIQUID CA ACITY. TANK INLE ELEV.. TANK OUTLET ELEV WARNING LABEL LOCKING COVER
10,
PROVIDED PROVIDED
t~~YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.. VENT MATT JHIGH WATER NU ER OF ROAD: !PRCFPERTr- WELL- B OILD ING: JVENTTOFRESH
ALARM FEET FROM / LINE. _ AIR INLET.
YES ❑NO ❑YES ❑NO NEAREST
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: PUMP AND CONTROLS OPERATIONAL NUMBER OF PH OP EH TY WELL JBUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM uNE AIR INLET'
PUMP ON AND OFF) ❑YES ❑NO NEAREST- 0
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing InAMF TEH atATE RInE AND MAHKIN
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'. LEND 7;:fN OF UISTH PIPE SPACING COVER DIA =PITS LIQUID
ENCE IALPIDEPTHDIMENSIONS G A
+a R+': EL LLPTtI FILL DfTH UI PI ' S pT}E DISTRPIPE MATERL NO ISTHNUMBER OF PROPERTY WELLBUILDING: VENT TO FRESH
BELOW PIPES ABO R EtIN(/F ELEj ,a PIPE LIN T_
FEET FROM
NEAREST 11-
MOUND SYSTEM: /2, 7
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 PE HM A N I NT MAH KF HS 013 S EH V A T ION WELLS
DEPTH OVER TRENCH eED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL ❑ YES ❑ N 0 ❑YES
SO UDFD SMULCHED ❑NO
CENTER EDGES
❑YES. ❑NO ❑YES 1:1 NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH -BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD =DTR ELEV E IPE MANIFOLD MATERIAL NO CISTH DISTR. PIPE
DISTRIBUTION PIPE MATERIAL & MARKING
LEV.' CIA. PIPES CI A..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT(-Y COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SI A _ //~~//J TITLE.
DI LHR SBD 6710 (R. 01 /82) ll//l/ 6 ,
wtsconsin APPLICATION FOR SANITARY PERMIT
COUNTY
(PLB 67)
OEPFIRTTEnT OF UNIFORM SANITARY PERMIT #
- In0U5TR4, IFIBOR 6 HUTRn FIELFiT10n5 U
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PRMTY OWNER MAILI G ADDRE
11 rr ,L1T_Vts (5 Z
PROPERTY LOCATION C
(A/4 91/4, S Z, T31, N, R *-(or) W LAGS: `
LOT N MBER BLOCK NUMBER SUBDIVI ON NAME NEAREST AD AKE OR L NDMARK STATE PLAN I.D. NUMBER
6: A,
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms: 13 ❑ 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 kZeepage 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: Leg. 5
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):
I ~ Q Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installat' of the private sewage system shown on the attached plans.
Na Plumber rintl: Signatur t~ PAiDIMPRSW No.: Phone Number:
Plumber's A ress: Name of Designer:
tej
ti
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Ant/ Fee: Date: ❑ Disapproved
~-0 (i6 El Owner Given Initial
f r0 A Approved Adverse Determination
Reason or a
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.
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ST. cRO c
OUNTY ZONING OFFICE
yt5 St Croix County Courthouse LG, JU,
T911 4th Street
.Hudson, WI 54016,
Telephone - (715)386-
4680
L
The St.' Croix County Zoning Office offers the ice of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Comnletion j2f this form I& essential, aQ that thg pro erty can Dg
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.,
WATER TESTING----------------------- a
-FEE: $ 35.00 J D • 0-
(For nitrates and coliform bacteria)
WATER TESTING FEE: $185.00
(For VOCIS)
SEPTIC SYSTEM INSPECTION FEE:. $25.00
(Determines if system is properly functioning at ;time of
inspection)
PROPERTY OWNER'S NAME:
J PROP. ADDRESS: CITY
gal Des ription 1/4 of th 1/4 of Section. , i 3 _N-R
Town of Lot Numb r72 ubdivision.
Color of hou a Realty sign by house? If so, list firm:
L
-A ~ Z'
PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires--a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER .TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the -home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
_z
Telephone Number C i z- C/ / L v d
REPORT TO BE SENT TO: (p,E,r,
CLOSING DATE:
signature
EDINA 9A~Ty INC.
CORPORATE RELOCATION SERVICE'S
1400 S HIGHWAY 100, SUITE 200
1141 NNEAPOUS. MN 65410
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• ST. CROIX COUNTY
WISCONSIN
ray ' ` .
ZONING OFFICE
S
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
November 19, 1992
Mary Brausen
Corporate Relocation Services
1400 South Hwy. 100, Suite 200
Minneapolis, MN 55416
Dear Ms. Brausen:
An inspection of the septic system on conducted e opro n perty1loc tee at 407
Hill Ave., Star Prairie, WI was At the time of inspection,
the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface chemical said.sysAccordingtem, and
em not
not involve any excavating o
there is the. possibility d def ects in the
not in any way twarrant
discoverable by this inspection. operation of this
or guarantee the continued proper functioning or op
once
system. It is recommdattheeprsystem olongedhlife of thisesystem
every three years. Therefore, may be dependent upon proper maintenance of the system.
Scly, i ere ,
Mary J. Jenkins
Assistant Zoning Administrator
cj
NOTE: This home has not been lived in for an undetermined amount
of time.
Edina Realty,,..
FROM THE DESK OF Mary Brausen
Lac. ~ ,
n.
~ Wit'
Edina Rya
Mary Brausen
Assistant Account Representative
Corporate Relocation Services
1400 South Lilac Drive
Minneapolis, MN 55416
Bus. (612) 591-6427
ST. CROIX COUNTY
d
" } a WISCONSIN
` > . ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
December 4, 1992
Edina Realty Inc.
Corporate Relocation Services
1400 S. Highway 100 - Suit 200
Minneapolis, WI 55416
To Whom It May Concern:
You informed our office that you did not want a water test done on
the property located at 407 Hill Ave., Star Prairie, WI. Enclosed
you will find a refund check of $35.00.
If you have any questions, please feel free to call our office.
Sincerely,
Jackie Stohlberg
Secretary
enclosure
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATJONS \ / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LO AT ON• SECTION: TOWNSHI / NI ALIT LOT NO.: BILK. NO.: SUBDI ISION NAME: e
Z1 lot) T VN/R or) W i
T NER'S UYER'S NAM MA Li N A RESS.
' ! ~ ~ ^i
u `
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: ICOMMERCIA~ DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
~idence ~ g Pi%ew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system ( V c'7 ° Z9
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTE :(options 1
CAS❑U ~S❑U ~S❑U ❑SM ❑Sill z°~l1
If Percolation Tests are NOT required DESIGN ATE:
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: Ilk
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH ,
MBER D~P~FH'ffd ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 97- o aG ? a I.s, n .s. ,L. S 17 -y'
Z fpg~ 1oli qr / S
PIZ
B-3 X67 PIE > (o t"
6 ZS '11, et 4/73
B-
oil
B-e CIO
~~Sln?4` I PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER +h"t"f-B AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- 1 ° o < 3
P- Z a 3 tp & 4 3
P_ NO 3 i/'* A/41
P-_ GtS o 3 /e 3
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 ELE"T 97
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1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print)- TESTS WERE COMPLETED ON:
I Z., C!; )4 5. z9, °96
ADDRESS-CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGN T
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SR - 6395
-Y
To be a accurate sail test, your report must include:
1. Cc ;
2. Th y indicate whethe silence or commercial project;
3, MA) or ccam nned;
4. Is . wn;
5. Co as. A SITE t1 ~RI_E F:OR TANK ONLY IF ALL.
0-11 L ) OUT BAS C
Be PL town here fc t
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9. C fixes as to dates, t I exernp_
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~
A l REVIATI lmo t II I SOIL. TEST
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
798-2239 (HAMMOND)
y .1 425-8383 (RIVER FALLS)
~j
HAMMOND, WI 54015
June 2, 1986
Carolyn Haag
Permit Division
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Carolyn:
Attached please find permit#75040, issued in the name of Marshall
Boumeester. This permit has been res&inded due to the change in
location of the system.
Pemit X179171 was issued to replace #75040.
Should you have any questions, please feel free to contact this office.
Sincerely,
Mary J. Jenkins
St. Croix County Zoning Office
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
DIVISION
LABOR 8i HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING
P.O. BOX 7969
MADISONIWI 53,707
CONVENTIONAL ❑ALTERNATIVE state pla +D Number.
asslg eol
O Holding Tank D In-Ground Pressure ❑ Mound
INSPECTION DATE:
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER:
Marshall Boumeester Star Prairie, WI
RFF. PT. ELEV. : CST REF. PT. ELEV
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
NW NE, Section 12, T31N-R18W, Town of Star Prairie Name of Plumber: SantaryPer Number
MP/MPRSW No. County
75 Q,
Gary L. Steel 3254 St. Croix
SEPTIC TANK/HOLDING TANK:
LIQUID CAPACITY: TANK INLET EL ANK OUTLET ELEV.: IWA ING LABEL LOCKING COVER
MANUFACTURER: IP VIDED: PROVIDED.
'YES ONO DYES ❑NO
BEDDING: AT L. NUMBER O ROAD: PROPERTY WELL: BUILDING: ~VENTTOFRESH
LARM LINE AIR INLET.
VENT OIA.: VENT M. HIGH WATER
A' FEET FR
DYES ❑NO NEARES
DYES ON
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPAC Y. PUMP MODEL U SIPHON MANUFACTURER. RWAR OVIID DLgBEL PLOCKING ROVIDED COVER
DYES ❑NO f "YES DNO OYES ONO
UMPAN CONTROLSOPE ATI AL NUMBER OF PROPERTY WELL BUILDING. AIR ENT N OTRESH
GALLONS PER CYCLE: FEET FROM LINE
(DIFFERENCE BETWEEN ES Nn NEAREST
PUMP ON AND OFF) - LFN(~~TR. DIAM ETER MATERIAL AND MARKING
SOIL ABSORPTION SYSTEM. Check the soil moistu a he dep of o ing FORCE
or excavation. (If soil can be rolled into a wire, co ction shal ea ntil MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: LlnuiD
WIDTH: LENGTH: NO OF D( R. PIPE G. MATERIAL: PIT INSIUE DIA. #PITS: DEPTH
BED/TRENCH TRENCH DIMENSIONS
G PROPERTY WELL: BUILDING: VENT TO FRESH
LINE: AIR INLET:
RAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. DISTR. NUMBER OF
BELOW PIPES: ABOVE COVER. ELEV. INLET ELEV. END- PIPES. FEET FROM I
NEAREST
MOUND 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-
meets the criteria for medium sand. TIONS MEASURED.
LC ERMANENT MARKERS OBSERVATION WELL LS
DYES ONO P
SOIVER TEXTURE.
DYES ONO DYES ONO
SODDED: 15t:EDED: MULCHED:
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL:
CENTER EDGES. DYES ❑NO
DYES ONO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER:
BED/TRENC H NIDTH LENGTH: TRNO.EOFNCHES LATERAL SPACING: GRAVEL DEPTH BELOW PIPE:
:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: V PESISTR. DDiSATR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV.. DIA.. ELEV.:
ELEVATION AND
DISTRIBUTION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
(INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY: PLANS.
DYES ONO _ DYES ❑NO
L~- NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: LINE:
FEET FROM
DYES ❑No DYES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
DILHR SBD 6710 (R. 01/82)
wlsconSln APPLICATION FOR SANITARY PERMIT , _
Awnnw~ DILHR (PLB 67) UNIFORM SANITARY PERMIT #
- DEPfiQT 1E11T OF
InDUSTRV, LH9- 6 HUMRn RELRTIOnS ✓ L~
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPE TY OWNER N
14
P OPE T L,QCATION ILLAGE.
1/4 1/4, S , T3/ N, R /9)E (or) W
LOT NUMBER BLOCK NUMBER SUBDIVISION N ME NEAREST ROA D , LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A: ❑ Repair
b"ew System ❑ Tank Replacement
El Privy
El Replacement Soil Absorption System ❑ Revision
Reconnection El Petition for Modification
❑
❑ Alternate System
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
El Seepage Bed El Holding Tank
Seepage Trench ❑ Seepage Pit
El Pit Privy
El In-Ground Pressure El Vault Privy
System In Fill
issued
❑ Existing, For Which A Previous Permit Is On File, Permit #
❑ 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 U
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installa of the private sewage system shown on the attached plans.
MPRSW No.: Phone Number:
Name o lumber (Print): Signatur
~~S - (7 S ►z~. arm
Name of Designer:
Plumber's Ad ess
COUNTY/DEPARTMENT USE ONLY
Fee: Date: ❑ Disapproved
Signature of Issuing Agent: ❑ Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate coursels) of Action Available:
DILHR-SBD-5398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
L
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.
. T
APPLICATION FOR SANITARY PERMIT
ST 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/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.
- R-
Owner of Property/0"5 C -L 7
Location of Property W 14 Section , T3/ N - R / b W
Taw strtp 01,11ag Pa (r ie
Mailing Address e- Icl~ f
y
Subdivision Name ,
Lot Number
Previous Owner of Property J, o n sen
Total Size of Parcel :3 • 44- acre s
Date Parcel was Created
Are all corners and lot lines identifiable? 7~-- Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume ,I- and Page Number 4-4-as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3.• Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) eeht%6y that att statements on this 604m ane tn.ue to the best o6 my (oun)
hnow.tedge; that 1 (we) am (ane) the owneA.(s) o6 the pkopen ty des c i,bed in th.i.a
kn6onmati.on 6onm, by viAtue o6 a wannanty de neeon.ded in the 066ice o6 the
County RegiAteA o6 Deeds as Document No. 2~g ; and that I (we)
pn.eaentty own the ptoposed d.c to bok the .sewage pob system (o& (we) have
obtained an easement, to hun with the above desen.i.bed pnopenty, 6o& the
constnucti.on o6 said system, and the came has been duty neeon.ded in the 066.iee
06 a County Reg<.sten o6 Deeds, as Document No. 1.
SIGNATU OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
4- Mo
DATE SIGNED DATE SIGNED
y
• r
ST C- 105 r
v
, y
H
. SEP'T'IC TANK MAINTENANCE AGREEMENT
z
St. Croix County
0
H
OWNER/BUYER &efiA&L h CT]
Fire Number
ROUTE/BOX NUMBER p
CITY/STATE CCU I r& 10 161, ZIP
!V ! _4, Section-!2- , T~N, R~
,
PROPERTY LOCATION: liv -W,
of. ~f~rlr~ St. Croix county,
UC(l a
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 pLimLer. 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 maj 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 t L progrn. "r of 1980, with the requirement that
heir systems properly
owners of all new sYStelAS agree to
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 H
three year expiration. o
E
z
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Dep+rt- "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
k& ~WW96~
DATE St. Croix County Zoning Office
P.O. ~ox 93
Hammoid, W 54015
715-7'a6-2239 or 715-425-8363
Sign, date and return to above address.
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LDINGS
REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DEPARTMENT OF P.O. BOX 7969
INDUSTRY, PERCOLATION TESTS (115) MADISON, WI 53707
. =AND
HUMAN RELAT-IONS (H63.090) & Chapter 145.045)
TOWNSHI MUNICiPALIT LOT N .:BLK. O.: SUBDI SION NAME:
LOCATION: SECTION- RU kor) n
'%V~4 MA I G A DRESS:
COU TY• WNER' YER' ME:
~f DATES OBSERVATIONS MADE
USE PROFILE DESCRIPTIONS: PERCOLATION TESTS:
NO.BEDRMS.: COMMERCIA DESCRIPTION: ~•New Replace
Residence 3 X New
S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUNT ( IN-GR1OUN15-PRESSURE: SYSTEM-IN-FILLHOL~DING TANK: RECOM NDED YSTEM(optior) 11)
S EI U 0 I U EA. S S X1 U
DESIGN A 4 E: If any portion of the tested area is in the
If Percolation Tests are NOT required
Floodplain, indicate Floodplain elevation:
under s.H63.09(5)(b►, indicate:
PROFILE DESCRIPTIONS W/
F SO
r~~s.5~/1'►a~ CHARACTER
OLOR, BORING TOTAL ELEVATION DEPTH GROUND EST.HIGHESTS TO BEDROCK IF OBSI RSV~ED (S EI ABBRV. ON BACK jEXTURE, AND DEPTH
NUMBER ®EFf+i'tRk OBSER RVED C S
5 v 8~ 9t sv
? ®3 ~ 8? 7
B- 3 Z, /110 ~ fo ,~l . S.~G /ice T 7.5
6L, Z-7 A610 (L /..s-,1.. OC1~w ~f~ • 1317•
'7 20- Z 5 ALA
B- 6
1 .4,
PERCOLATION TESTS
DROP IN WATER LEVEL-INCHES RATE MINUTES
PE ~D 3
TEST DEPTH, WATER IN HOLE TEST TIME PER INCH
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2
P- 3 A) 0
v 3 3 V l
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 ELEVATION1~ 99 3
.
,
7 ; F
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1_70' TIL
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TN
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1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
\ tTT S WERE C OMPLETED ON:
NAME (Print 8 06
TIFICATION NUM E : PHONE NUMBER(optional):
Q/ J
ADDRF,S~YY S URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
' T RUCTION FOR COMPLETING M 116 - S BD - 6396 .J
c=r-ate soil test, your resort must incluc:le:
to w hell rhifi is -r commercial project;
r 1, .
>UITAB" 'z- TA_ = ALL
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2t;
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