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77
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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~1Lq/?l? TOWNSHIP ,<SEC. T ,_,LN-R2,~' W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERYTHING WITHIN 100//FEET OF SYSTEM
i
I
I
c
a
/14/1
cac~~ ~~A,CJ
INDICATE NORTH ARROW
c~<~
BENCHMARK: Describe the vertical reference point used
C~„
Elevation of vertical reference point: ~~!l! Proposed slope at site:
SEPTIC TANK: Manufacturer:/,2/,~;,, . ~ -Liquid Capacity: lz~nO C
Number of rings used: Tank manhole cover elevation: 9f~~
Tank Inlet Elevation: Tank Outlet Elevation: '
Number of feet from nearest Road: Front 10 Side,O Rear, feet
From nearest property line Front 10 Side,O Rear, 0. feet
Number of feet from: well 76 ' building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
i ovv nVT7VnVV c+rnn
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:
~r
Width: Len$th:Number of Lines: Area Built:.'
r
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. ~
Number of feet from well: 91J
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box 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 of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: -
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
M7CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE:
Wayne Berg Rt . 3, New Richmond, WI 54017 r 3~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SW SE, Section 12, T31N-R18W, Town of Star Prairie, Lot#5, Johnson sub ivison
Name of Plumber: MP/MPRSW No, County Sanitary Permit Number:
Cal Powers, Jr. 1563 St. Croix 79129
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: C/C LIQUID CAPACITY: TANK INLET ELEV.: OUTLET ELEV.WNING LABEL LOCKING COVER
~ P IDEDI PROVIDED
61i 11'~ Lr G'1? y lI~ YES ❑NO ❑YES NO
BEDDING: VENT DIA. VENT MATL. JHIGH WATER NUMBER OF ROAD: PROPERTY . WELL: BUILDING: JAIR
VEN
TTOFRESH
ALARM"~..~/ FEET FROM I LE
❑YES t'NO ❑
l YES LJhO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. 1PU"P/SIPHON MANUFACTURER: t fEMATERI,1:1 LABEL LOCKING COVER
PROVIDED:
YES ❑NO " ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBS F LBUILDINGVENT TO FRESH (DIFFERENCE BETWEEN FEET F M AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEAR
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 r,i TH ' AAND 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: JH NO OF DISTR PIPE SPACING. COVER NSIU;ED IA #PITS LIQUID
TRENCHES. IAL' PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO TR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPE&. ABOVV COVER. EL V. INLET ELE END. , J n PI FEET FROM LINE r' AIR INLET:
° ' ?i
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: JO RVATION WELLS.
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED: SEEDED. MULCHED:
CENTER. EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH. LENGTH 'NO.OF LATERAL SPACING. JGRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER.
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV.. DIA.. ELEV.: PIPES: DT:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDSTOAPPROVED
PLANS: ❑
❑YES ❑NO YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
l
61
Sketch System on Retain in county file for audit.,
Reverse Side.
SIGNATURE: LE:
DILHR SBD 6710 (R. 01/82) TIT
mmb~ wtsconsln APPLICATION FOR SANITARY PERMIT
(~IDILHR COUNTY
(PLB 67)
- OEPRRTTEnT OF UNIFORM SANITARY PERMIT #
InOU5TR4, LRBOR 6 HUMRn RELRTIOnS
-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
PROPEf TY OWNER MAI G ADDRES
41,66wiA.
PROPER~W LOCATION ic7n y
TOF1/41/4, S / N, R E( (or ow :
YW) sl-~ 95:29~
LOT NUMBER BLOCK UMBER ISUBD)VISION NAME NEARESTJ30AD, 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:
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.
21 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:
ar
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 installation bf the private sewage system shown on the attached plans.
Na f P(Gmber (P t): IS igturgMP/MPRSW No.: Phone Number
rz
Plumber' Address: Name of Des' er:
X
COUNTY/DEPARTMENT USE ONLY
Sign ture of issuing A nt: ¢Fee: Date: ❑ Disapproved
Q✓ ( O ~L ❑ Owner Given Initial
L1 v Approved Adverse Determination
Reason r Disa ro
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.
_j 244i
Location of Property,( J 14 ma14, Section T,_N-RW
Township 2~2,e
Mailing Address
Address of Site
Subdivision Name c/- t
Lot Number
Previous Owner of Property
Total Size of Parcel i'
Date Parcel was Created / 4
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume /_37 and Page Number 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTV OWNER CERTIFICATION
I (We) cetti jy that aU Statements on this 4otm ate t ue to the best o6 my (out)
knowledge; that I (we) am (ake) the owneh(.6) ob the pnopetty de~scA bed in tW
dnjotmat on jotm, by viA tue o6 a wattanty deed tecotded in the 0jjice of the
County Regi6tet o6 Deena cvs Document No. and that I (We) ptesen 2y
own the ptopoz ed z to jot the b ewag e digs pots syA em (ot I (we) have obtained an
eabement, to tun with the above desnibed ptopehty, Got the eon.6tAucti.on o6 .said
syztem, and the .same has been duty tecotded in the 04jice o6 the County Register o6
Dee6 , as Document No.
SIGNATURE 0 OWNER SIGNATURE OF CO-OWN (IF APPLICABLE)
DATE SIGNED DATE SIGNED °
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
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OWNER/BUYER H
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ROUTE/BOX NUMBER Fire Number
C ITY/ STATE J Z IP I
PROPERTY LOCATION: ,4) 14, S 14, Section, T N, R W,
Town of St. Croix County,
7 ,
Subdivision --~-"rt 1G+~,t1 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
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
E
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.
SI_,GNED
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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DART of REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS l / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LO I / SECTIO~~3//R~ ,or *TOWNSHIP/MU~~LITY: T OT NO.:BLK. SUBDIVISION NAME: gi 2,0 41,- 1 c '4 1 CO NTY: O ER'S/BUYER'S NAME:
AI I G ADDR S.
S
USE DATES OBSERVATIONS M OE
NO. B MS,: 1COMIVERCIA DESCRIPTION: ~ PROFI E DESCRIPTIONS: JPERCOJLATION TESTS:
Residence [2New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTE -IN-FILL HOLDING TAN ECOMMENDEDSYSTEM:(optional)
Qs []U [Zs ou ; OS ou ❑s RU ❑s Zu
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: S Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
f
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ft, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B-
- y r
B- qA9
B-
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER hS AFTERSWELLING INTERVAL-MIN. PERIOD 1 PE RIO 2 PERT PER INCH
P- 1
P- / 7
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.
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SYSTEM ELEVATION
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I, the undersigned, hereby certify that the soil tests'reported on s orm w a de by me in a cor with the proce ures nd methods speci ied in t e 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 (prin~): J
TESTS RE COMPLETED ON:
jt~
A SS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
i, ~AAft,')'d M~;~ / _ S-
CST G RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
II STRL - FOR COMPLETING ORm 11 - SBD - 6395 t
To ..,ii test, YOUr report MUSt inClUde:
1. C_
2. e whether this is r e or commercial project;
3. K Commercial use _
4. Is
S, G poxes. A SITE IS FOR A HOLDINI- TRIII l< ONLY IF ALL
OUT BASFn ` ONDITIONS;
. Pi 5 own here fo descriptions a the plot plan;
7. aurateiy la €`ations. DraI, preferred. A
r! i ;
e clea'az s , P permanent;
s, w ! pl< o rt exernp-
10, If the e appropriate box;
11. Si
12 " - - _ED WITH THE
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PAGE OF
CroSS Secjlun O~ A 4~en SySt'er"
W ~
7~3 Fresh Air Inlels And Observation Pipe
Approved Vent Cop
sy/~/7 Minimum 12" Above
Final Grade
F
4" Cost Iron
20- 42" Above Pips
To Final Grade Vent Pipe
Marsh May Or Synthetic Covering
attn. 2" Aggregate
Over Pipe
Olatribotlon -Tee
Pipe 0 0 0 0 0
i
Beneathepipe ° Perforated Pipe Below
o Coupling Terminating At
Bottom Of System
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PruPoser~ 1"inal 19rH~1{ ~
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SOIL FILL
DISTit10UTlOt.] PIPE
APPRDVED S4MIETIC COVER
'`'-MATERI^t OR q" OF STRAW
G SGREf OR (JARSN HAy
10'OF -21/2 AGGREGATE e8
t5 I
ELEV. aFy FEET,
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DISTRIP5IJTIOIJ PIPE TO BE AT LEAST_ INCHES BELOW ORIGINAL GRADE
ANU AT LEAST20 INCHES BUT AIO MORE THAI) H2 RICHES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXCaVATIOP FROM ORIOVAL 6RADa WILL BE _ INCHES
MINIMUM W" OF EXCAVATION FROM 0IRI(AW41- GROE WILL BE ~ INCHES
SIGIJED: t
LICENSE AJUMBER:
f
~ - XC~.
DATE: