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Form- S T C - 104
AS BUILT SANITARY SYSTEM RE
OWNER rZfJ2
TOWNSHIP SEC. TN-RW
ADDRESS ST. CROIX COUNTY, WISCONSIN q41D
SUBDIVISION LOT J LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
,ate
7~t
Q
INDICATE NORTH ARROW
G s~
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
0
41
SEPTIC TANK: Manufacturer: Liquid Capacity: /410o
I
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, O feet
From nearest property line Front 10 Side,o Rear, O r7feet
Number of feet from: well, building:
(Include•'this information of the above plot plan)( 2 ref
_ erence dimensions
to septic tank)
_ CC L` DL'~7L'D CL' CTTD
-awl%
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: 4)( Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe: r
Number of feet from nearest property line: Front, Side, O Rear,/7\1t .
Number of feet from well: 105Q.-
Number of feet from building: 1,2-
(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 0 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 of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: f Plumber on job: ae~
License Number: /
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR,& HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707~8g BUREAU OF PLUMBING
Ls~ONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned)
4
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Allen Bentley Rt. 2, New Richmond, WI 54017 n
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN J
REF. PT. ELEV.: CST REF. PT. ELEVi
SW SE, Section 12, T31N-R18W, Town of Star Prairie
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Cal Powers 1563 St. Croix 79125
SEPTIC TANK/HOLDING TANK:
JMLIQUICAP CITYTANKINLET ELET ELEV.WARNING LABEL JLOCKING COVER
- PROVIDED: PROVIDED
YES ONO OYES ONO
BEDDING: VENT IA.: VENT MATL.: HIGH WA R NUMBE CAD: PR P€RTY WELL: IBUIL NG: VENT TO FRESH
ALARM. FEET FROM Lf /Ts J AIR INETYES ONO YES ONO NEAREST 71
115O SING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. NI NG LABEL LOCKING COVER
WAR
PROVIDED: PROVIDED:
OYES ONO OYES ONO' OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING: VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) OYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Frj"I H 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 EAR : LENGTH NO. OF DISTR. PISPACING. COVER INSIDE CIA #PITS LICUID
THEN M IAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH EPTH DISTR. PIPE DISTR. PIPE DIST PIPE MATERIAL: O rR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELO/W ; 0 OVER: E V. I. E D: LINE: A
MOUNDS STEM:
O YES ONO IR LETFEET FROM NEAREST -s
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.
SOIL COVER TEXTURE PERMANENT MARKERS 7RVATION WELLS
OYES ONO YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER EDGES.
OYES ONO OYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH . WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEVATION AND ELEV. ELEV. DIA.: ELEV. PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
OYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
OYES ONO OYES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGN TUR - TITLE:
D I L H R S B D 6710 (R.01/82)
iulsconsln APPLICATION FOR SANITARY PERMIT
D I L H R (PLB 67) COUNTY
OEaaaTRIEnTOV UNIFORM SANITARY PERMIT #
InOU5Tg4, LRBOR 6 MUTRn gELRTIOns '.1
~ ~Z'U
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PR E TY OW ER MAI NG ADD SS
P OPERTY LOCATION Coq; )
1/4S 1/4, S , N, R/9 9 (ord TOWN OF: J
LOT NUMBER JBLOCK UMBER ISUBDIVISION NAME NEAREST$QAD, LAKE R LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify): jj Z~
THIS PERMIT IS FOR A:
W 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.
rX 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:
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 installat' n of a private sewage system shown on the attached plans.
Na f umber S* na r MP/MPRSW No.: Phone Number
6
P um 's Address: Name of Design :
COUNTY/ DEPARTMENT USE ONLY
Si na re of Issuing Agent: Fee: Date: ❑ Disapproved
L--o7S ~6 ❑ Owner Given Initial
Approved Adverse Determination
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
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 A2:94 "4 el
Location of Property _ U/ 14, Section T7_N-R /do W
Township .STA.P /O~l/S7i~lGS' ST,Q//' l1_1rr
Mailing Address auz' x "dEar R k
Address of Site
_~~~v i2~zH.h o.v,0 L✓/ sSEQ /Z
Subdivision Name
S 4W4-dr o..~
LotSNumber 9 £ /p
i r
Previous Owner of Property
Total Size of parcel ,?(qGR
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 7,3 7 and Page Number I&W 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 Resister of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) eexti6y that aU .statements on thin bonm alte ttcue to the best ob my (oun)
knowtedge; that I (we) am (atce) the owneAW o6 the p4opetLty denscA bed in thus
in4o, mation 6otcm, by vi tue ob a walvcanty deed ttecotcded in the 066ice o6 the
County Reg-i 6 teA o6 Deed6 " Document No. ; and that I (We) pne~s entt y
own the pttoposed site Gott the b ewage dus p _d y em ( ott I (we) have obtained an
eabement, to nun with the above dacAi.bed pupwy, bott the constnucti.on ob said
.6y6tem, and the same has been duty &eeo&ded in the 04gice o4 the County RegisteA o6
Deed6, as Document No.
SIGNATURE OF OWNER 7 SIGNATURE OF CO-OWNER (IF AP ICABLE)
DATE SIGNED DATE SIGNED
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
t7
a
OWNER/BUYER eox." ir, t~~"'V'rLG''A- ~
ROUTE/BOX NUMBER e
nU MZ Fire Number a (e
CITY/STATE
,P«i~jyD~✓O .l,~iSCe...fis,~ ZIP $gd/y
PROPERTY LOCATION: S.l.,/ Section, T_/N, R 18 W,
Town of :5';oWe St. Croix County,
i
Subdivision)e&/.vre., s= .esss : Lot number F Q.
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. Ho
E
I/WE, the undersigned, have read the above requirements and agree Ln
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 c0
(gW
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.
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IN
INDUS-TRYRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUS, c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
I.OCATION: SECTION: p t TOWNSHIP/Mb'N+e+P-rLITY: LOT NO.: BLK. O.: SUBDIVISION NAME:
/T3 N1R 4 f or _
COUNTY OWNER'S/BUYER'S NAME: MAIL G ADDRESS
USE DATES OBSERVATIONS MAD
I~ NO. BEDRMS.: ICOMMERC AL DESCRIPTION: PROFILE DESCRIPTIONS: PER CATION TESTS:
y_u Residence New ❑ Replace.
RATING: S= Site suitable for system U= Site unsuitable for system IUNA COM MS DU . M®S, ❑U IN G~ P~~ RE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
If Percolation Tests are NOT required i DESIGN RATE: [Floodplain, any portion of the tested area is in the
under s.H63.09(5)(b), indicate:
indicate Floodplain elevation:
S
4,14
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH p4, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
Alb" B- }
B- S
B-
PERCOLATION TESTS
C
TEST DEPTH, WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER J.~ AFTERSWELLING INTERVAL-MIN. PERIOD PERT 2 PERIOD 3 PER INCH
P-
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.
~ NbaS,E
SYSTEM ELEVATION
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Sir-
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r 1711,
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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,(Rt{int): TESTS W E COMPLETED ON:
ADDR -
CERTIFICATION NUMBER: PHONE NUMBER (optional):
C IG ATU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - S BD -
°-srl test, your resort mu- ~-,--Je,
y iether th ,ornmercial project;
Vl ci
4, a ew or
t ',SITE ISL....T,7. HOLDIN'" { ONLY IF ^',L
3ASE??
6. .`L w l here f4 e
7. M curately locatin y€ I. A
se
8. M rrerlt;
Kemp-
9. C,
1t3 k in thr e box;
~1.
12 !w. BE Ell__J WITH THE
301L TESTERS
C 1s
Ht
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aarn
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Six cue
fo
Po i rl t
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TO T1
T it test rep( request
i s c t vat(
i!rt<s
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96
71
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q PAGE OF
r~
CroSS Seejlun O~ A Ze0 Systen-)
Fresh Air Intel$ And Observation Pipe
C~),~'~ -
Approved Vent Cap
5017 Minimum 12" Above
Final Grade
4" Cost Iron
20- 4 2" Above Pipe
To Final Grade Vent Pipe
Marsh Fay Or Synthetic Covering
Min. 2" Aggregate
Over Pipe
Olstrlbutlon -Tea
pipe f
0
o Perforated Pipe Below
Bo
Coupling Terminating At
Bottom Of system
j
P~~PoSeD ~Inal 9rac`•t
N
SOIL FILL
DISTRIBUTIOF,] PIPE
APPROVED S4MTHETIC COVER
OR 9" OF STRAW
OFMCAEGA1E. e OR MARSH HAy
tee OF -Zi/2 AGGREGATE e8
ELEV. OF97,'/- FEET-.
F- 2"
DISTRIBUTIOAI PIPE TO BE AT LEAST INCHES BELOW ORIGINAL GRADE
ANU AT LEAST20 INCHES BUT AIO MORE THAN H2 IAIGHES BELOW FINAL GRADE
1WW4UM DEPTH OF EXCAVATIOP FROM OR1610►AL GRADE WILL BE AS-9v _ INCHES
PUI41MUM Bf.FTIt OF EXCAVATION FROM. 0 1161MAL GRAVE WILL BE INCHES
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I
SIGNED:
LICENSE NUMBER: I
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DATE: