HomeMy WebLinkAbout038-1126-70-000
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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER I 'It TOWNSHIP SEC. _ TLN-R1,W
ADDRESS 1 ST. CROIX COUNTY, WISCONSIN
' c
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
C
ck G+ ' I 'aft,
/ n
,Sirl • 3.0
,~Eq 7 /3 = q~
INDICATE NORTH A ROW
BENCHMARK: Describe the vertical reference point used,
Elevation of vertical reference point. O
Proposed slope at site:,-
SEPTIC TANK: Manufacturer: V&f Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation - Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side 0 Rear,
feet
.From nearest property line Front ,O Skde,(nRear, O
feet
Number of feet from: well -3s- ! , building: /,r f
(Include this information of the above plot plan)(
2 reference dimensions to septic tank)
PUMP CHAMBER /
Manufacturer: ;L4C'2L:, Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
/
Elevation of inlet: i Bottom of tank elevation: J
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: c~ Alarm Switch Type: /
f
Number of feet from nearest property line: Front, O Side, ORear,0 Ft
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe: f
Number of feet from nearest property line: Front, O Side, O Rear, Ft.
Number of feet from well: / Leda, Number of feet from building: S w
(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 : /G
3/84:mj
-Mow
E
ABOR PARTMENT OF INDUSTRY, INSPECTION REPORT FOR & HUMAN RELATIONS SAFETY & BUILDINGS
.0. . BOX 7969 PRIVATE SEWAGE SYSTEMS
~ DIVISION
ADISON, WI 53707 BUREAU OF PLUMBING
❑CONVENTIONAL UALTERNATIVE Slate PHn LD. Numlxr
❑ Holding Tank In nefgnENl
UM-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER.
INSPEC 110N DATE
Edmund Halkoski Rt. 1, Somerset, WI 54025
ENCH MARK tVerms-1 reference pomR DESCRIBE IF DIFFERENT FROM PLAN.
FIEF. PT. ELEV.: CST REt. PTrELEV
NW NE, Section 31, T31-R18W,*Town of Star Prairie
I".. Of PWodwr, MP/MPgSW No..
County Samtdrv Pe(mn Number.
Cal Powers 1563 St. Croix 83839
EPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY
TANK INLET ELEV. TANK U7 W
LET LEV ARNING LABEL LOCKING COVER
i., ( f a / P 1DED PROVIDED -
BEDDING ; YES ❑NO ❑Y ES NO
VENT DIA. VENT MAT L. ALAI WATER NUMBER OF ROAD: PROPERi WELL 9UILUING VE 44 TO FRF SR
ALARn1 FEET FROM LINE Alit INLET
❑YES NO I ❑YES NO NEAREST
OSING CHAMBER:
MANUF ACTUREH BEDDING LIQUID CAPACITY PUMPMODEL PUMP. SIPHON MANUf AC RIREH
n NO WAIININOLAFIEL LOCKING COVER
UJ~"v> ❑YES t~INO ? U, 7 PROVIDED PROVIDED
GALLONS PERCYCLE: puMPANOCOrvrgolsOPERATIONAL YES ONO YES JNO
(DIFFERENCE BETWEEN NUMBER OF PI+++1'F I+IV Wt Lt Huu IN(, VENT TO 1141 511
PUMP ON AND OFF) 8 17 FEET FROM LINEq AIR INL F T
9YES ❑NO NEAREST-> L
01L ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing F F N ,u/ nlnnn n n vn n Hlnl nND MnHKIN(.
r excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
he soil is dry enough to continue.) MAIN
ONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE PACING COVER
TRENCHES M1IATERIAL' IN51111 111.1 sV,IS I IO()ID
DIMENSIONS I S114 f, III (,HAVE L U PTH FILL COVER UISTR PIPf. DI PIP ERIAL NO UISIH PIT NUMBER OF WELA. HUILUING VE I,NFTI,ITff
IIf LOW PIPES ABOVE 1 II V V I W I I ELEV END PHUVEHiY
O 1 I/f tin
PIPES FEET FROM ,LINE
AIN INl [ 1
OUND SYSTEM: NEAREST
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it . ON REVERSE SIDE. SHOW ELEVA-
❑YES ❑ NO meets the criteria for medium sand. TIONS MEASURED.
OIL COVER TFxTURE
PENMAN( NI MARK( NS (gstit flVn IH IN WI I 1 S
DEPTH OVER THE NCH BEU DEPTHOVIH FRENCH BED DYES ONO OYES NO
CFNTEH EDGES NEPTHOF TOPSOIL 5r1UDf 11 5FI1)F D
MUI (.Irf U
❑YES ❑NO DYES ❑NO ❑YES )NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LE NUT" NO.OF LATERAL SPACINr; NAVEL OF P711 HE LOW Vlpj-~
DIMENSIONS G 1 TRENCHES 1 II L OF P111 AH0VI COV! 1,
`J J
MANIFOLD
F V FPLDEPJ VAN" O' IT UIS(q PIPE MANN OLD MATERIAL NO DISIII 1,15111 PITT I)ISIIUHUIR)N 1'11'1 n1 P, II IIIAI &NIATI IN(ELEVATION ANO DIA 2 ELErs;
PIpf S Dln
DISTRIBUTION `J l•.: /
INFORMATION HOLE `IIF HUIESPACING UIIILIlUf.(1HNFCity
7
/ COVEH MA TE HIAL Vt H I WAI 1 11 1 LOH11151UNDS I() APPH(rV11)
PL ANS
COMMENTS: PERMANENT ARKER : YES ❑ OBSERVATION - ❑YES ❑NO
WELLS: NUMBER OF PF+OPERTY WELL BUILDING
FEEI
YES ❑NO Y LINE
ES ❑NO NEARESTOM. /~f MN
+Ir
Sketch System on
Reverse Side. Retain ' county file for audit.
SIGNATURE TITLE v
SBD 6710 (R. 01/82)
SANITARY PERMIT APPLICATION COU
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY P RMIT # 91
-Attach complete plans (to the county copy only) for the system, on paper not less than '383
STATE
8%z x 11 inches in size. PLAN I.D. NUMBER
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION
FOR VARIANCE ❑ YES ❑ NO
PROPEVTY,OWN PROPERTY 0CATION J
~/a '/a, S~ 1 N, R I~ (or)
PR ERTY OWNER'S MAILING ADDRESS LOT NU BER BLOCK N MBER SUBDIVISI N NAME
CITY, STATE ZIP CODE PHONE NUMBER CITY N=7a OAD, AKE OR LANDMARK
VILLAGE : - 1 -2- TOWN 11. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. ❑ New b.)XJ~ Replacement c. ❑ Replacement of d. E1 Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement-to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. ❑ Conventional b. JK Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ga I I G P
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. W Seepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet ® Private El Joint 1:1 Public
VI. TANK CAPACITY
in allons Total # of Prefab. Site Fiber- Ex
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App.
Tanks Tanks structed
Septic Tank or Holding Tank ❑
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.
Plu er's Name Print): P er's Signature- (No mps) MP/MPRSW No.: Business Phone Number:
um is A dre s (Street, State, Zip Code : Name of Designer:
VIII. SOIL TEST INFORMATION
Cert' 'ed oil Test CST) Name CST #
C DDRESS Street, b , ate, Zip Code) Phone Number:
25-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps)
X Approved ❑ Owner Given Initial Surcharge Fee /y? Q~yf/
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
a
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date-, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number-of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be -
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage syster contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
1I. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
Ill. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/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&rat?' -
included the creation of surcharges (fees) for a number of regulated practices which Wiscori,:'n'5
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried I, ea_.,a,e
is used in your building is returned to the groundwater through your soil absorption;
system or the disposal site.-used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- 1
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03/86)
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UL 2 8 i°86 i
PLUMBfNG BUREAU
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/L E/ILS f /1 f/ i r l. v tU, 4-4 a RECEIVED
11 PLUA4 ING BURSAU
. GY ~7~ L1 1 PAGE z OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VENT CAP
4"C.Z. VENT PIPE
WEATHER PROOF APPROVED LOCKING
23' FROM DOOR, JUNCTIOM BOX MANHOLE COVER
WINDOW OR FRESH 12"MIU. t ~u~ ,~i s
AIR INTAKE
GRADE
I
( M"MIN.
CONDUIT
le"MIN•
INI_.EI- PROVIDE I
AIRTIGHT SEAL ( I i I `
T
APPROVED JOINT A £ e la I (I APPROVED JOWT
W/C.I. PIPE. rx I I I W/C.I. PIPE
EXTENDMIG 3' - ' I I I EXTE►JOIAIG 3'
O►ITO 50C.I0 SC,L L'o < ALARM
B I I ONTO SOLID %OIL
~UY Oki
c
P
OFF
ELL
COUCKETE BLOCK
RISER EXIT PERMITTED ONLY IF TAIJK MANUFACTURER HAS SUCH
SP
EGIFIGATIOtiIS
SEPTIC AND
DOSE TANKS MALIUFACTURER: NUMBER OF DOSES: PER pA.4
TAWK SIZE: _//%o(% GALLOIJS DOSE VOLUME
ALARM MAUUFACT UKER: 1 ALL ~i~_5~~.~~ INCLUD!►!;, ZAC! FLOW: GALLONS
MODEL NUMBER: CAPACITIES: A=YIMC14ES OR GALLOUS
SWITCH TYPE: B =-INCHES OR fy~ GALLOAIS
PUMP MANUFACTURER: C = Y INCHES OR 12_ GALLONS
MODEL NUMBER: ;-1
D- .12_ INCHES OR 3424 CALLOUS
SWITCH TYPE: IJOTE: PUMP AND ALARM ARE TO BE
PUMP DISCHARVE RATE ,1471) 1; P1A44 sE 4/, Ov) INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCIE Ci4'WEEu PUMP OFF AND DISTRIBUTION PIPE.. Q• y FEET RECEIVED
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . , . . ~2.`5,j~ FEET JU 2
+ /f1 FEET OF FORCE MAIN X FT~. FEET ~'LU ~Q86
X100 FT.FRICTIOAI FACTOR.
TOTAL. DYNAMIC. HEAD FEET MBING BUREAU '
INTERMAL, IMEWSIOMS OF TANK: LENGTH Li
;WIDTH---,-- ;LIQUID DEPTH
SIGNED:
LICEMSE NUMBER: - DATE:
-117-
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SC7/l1.aX4S,E J ~ ~ '
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60<1
ltd i; ~JUL 28
1%6
PLU&4F31NG BUalzA
Model 3870 Submersible '0
Effluent Pumps
140 -
i
4 ,Iwl"
rit OSx~[ 120 ~
s
.2.100
0
~80
4
v
= wp
E
c
60 wp M
1
lt,P -
-40
WP 03, 'h H P. - - -
20 W 3j-% H.P1 -
0 40 60 + 80 100
CaPadty - Gallons PerMlnuta
04516
M.P. Order No yon$ PAS Max. WL
WP0311E AmM RPM 5011dt (fts.)
A WPMWIIE 115 9.4
WPO312E 1750 56
W- PMM12 230 10 4.7
WPHMIIE 1t5 ~
WPH0512E 230 8.0
WPH0532E 3.4 60 30 WPHOS34E 460
WPH0712E 1.7
230 10 9.0
WPH0732E 208/23D
WPHO734E 30 5.4
~ 2.7
WPH1012E 230 10 11.6 70,
t WPH1032E 2161230 X50
WPH1034E 30 6.4
4G0 3.2
WPH1512E 230 1~ 13.3
WPH1532E 208/?3p 92 RE~'E~VE
u 1'h WPH1534E 460 4
17. I'll, 111.11,11,111,11, WPMM1512E 230 10 4.6
l WPHH1532E 208/230 t32 I 8
r 9.2 i Qg6
WPHHt534E 30
460 IA
SPECIFICATIONS ARE SUBJECT TO CHANGE WITHtUT
&A
3
Step 6. SIZE THE FORCE MAIN
A) System discharge rate
it
B) Force main diameter
C) Friction loss will be 1- ft./100 ft.
Step 7. TOTAL DYNAMIC HEAD
A) Vertical lift j ft.
B) Friction loss / ft.
C) TDH ft.
Step .9. SELECT A PUMP
foul /7e'~ r~ ~ 70) 1JPJ 10 Uld
Step 9. DOSE CHAMBER SIZE
Step 10. DOSE VOLUME
/ Ei(Al /roc fr./ ~f', tXl'7)~9>2'~A'/sX ~ov 6/aio Ua/h,c /C1~; }~X' /C ~J /~U.7 y~
w SlA)~
t ,
RECEIVED
JUL 2 8 i986
PLUA4f3fNG E31j{jEAU
WORKSHEET - PRESSURE DISTRIBUTION NETWORK DESIGN
/ PROBLEM
~;n i4 Ss~ f ~ J~ S
Design a pressure distribution network for a _ bedroom home. The site
characterisitics are:
Depth of groundwater or bedrock S in.
Landslope 3_ %
Percolation rate c min./in.
Distance from dose chamber to distribution system ft.
Elevation difference between pump and distribution system ft.
Step 1. ESTIMATE WASTEWATER LOAD
Step 2. SIZE THE ABSORPTION AREA
A) Area required
fill 4
R) Select length
C) Width
D) I will use a manifold.
Step 3. SIZE DISTRIBUTION PIPES
A) Hole s - ze I wit; use is / in.
g) Hole spacing I will use is _ -2y~ in. 53( 4515
C) Lateral length is~ ft.
D) Lateral size'- in. QED
Step 4. DISTRIBUTION PIPE DISCHARGE RATE Jul 2 8
~~~~,j ~ t9~~
a9 //W, e~~~~r~
Step 5. SIZE MANIFOLD
A) Manifold length ft. s/GN -
B) Number of distribution pipes = .Lies-ash la ~s6 s
C) Manifold diameter ? in. ~7- 7-,(5'6
STATE-OT WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
~DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
• P.O. BOX 7969 MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township f4XiRXpRX
NW 14 NE 34 S 31 T 31 N/R 18 A W Star Prairie St. Croix
Street Address: Subdivision: County:
Landowners Name: Mailing Address:
,Ed Halkoski Rt. 1 Somerset WI 54025
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
w suited for a conventional private sewage system. If approval is granted, I
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and-date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy s
application. 0451
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
RECEIVED
r
JUL 2 8 19ge.~k
Signature of Applicant Date
PLUMBING BUREAU
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF This C~v day of 6.u,4 19Cl/ al,
Rose M. Bdbirpon ; ~
NOTARY PUBLIC Notary Pu)L-49Z"_,&,~~
blic, State o Wisconsin
STATE (F VAMNSIN
My Commission Expires: /op-49
DILHR-SBD-6413 (N. 05/81)
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location NW 1/4, NE 1/4, Sec. 31 T 31 N, R 18 Mkx W
Town 10rXNffldK0A11ty Star Prairie Street Address
Lot No. Block Subdivision
Landowner's Name: Ed Halkoski
The application for this site is for:
❑ new construction use.
Filreplacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
(.1 to have one of the first five approvals guaranteed for this year. This is
number - - of those applications. (Use one of the first five
quota 6-5-mTers-i 'issued to you.)
]one of the applications needing a quota number. The quota number assigned to
this application is - .
0 for one additional.homesite on a farm to he occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
Ifor an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department. 1904
L_]for an application on file prior to February 1, 1980. Ark A
L]for a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT -)YSTEM USE, the alternative private sewage system is
replacing:
E la failing conventional soil absorption system.
RFC
1 a holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
If this is a ~N~ 1986
checkhheret meets the criteria for a ~U~Fq
conventional REPLACEMENT
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Nelson Si ure
County Official
Title Assistant Zoning Administrator Date July 21, 1986
DILHR-SBU-6158 (R 12/82)
DEPARTMENT OF t REPORT ON SOIL BORINGS AND SAFETY ~k BUILDINGS
INDUSTRY,- DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ 1 MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATIOjNS ECTION: TOV~(NSHIP/MUN+C+PALtTY: LOT O.:BLK. SUBDIVI ON NAME:
/4 (or
/T N/R ~l I -
'COUNTY: OW 'S BU S NAME: M L ADDRESS:
USE 1 DATES OBSERVATION MADE
NO. BEDRMS.: COMMERC LDESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
❑ New Replace
Residence
I 14
RATING: S= Site suitable for system U= Site unsuitable for system / -
ONVENTION E MOUND: IN-GROUND-PRESSURE: SYSTE -IN-F L OLDING TANK: RECOMMENDED SYSTEM: (opti6 al)
orSzU11zS0U1 Zs❑u os Yu as u _ Z3e
y portion of the tested area is in the
If Percolation Tests are NOT re wirer DESIGN RATE' It an
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: .1114
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH TR. ELEVATION OBSERVED S IGHE T TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.)
'Sr _3 3L &1124
B- - S'
B-
B-
iD~Ilc
1 9-19 1 JVIVA6e
B- r S
PERCOLATION TESTS
TEST bEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IAl6FFE8 AFTER SWELLING INTERVAL-MIN. p I D 1 PERIOD2 PEFJ D PER INCH
P i )
P- 2&
P ,r
P
2-
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
zontak "d vertical elevation reference points and show their location on the plot plan. Show the sur a io a I irpt and the direction and percent
of land slope.
SYSTEM ELEVA IONS f~l a~
,rV--a1A.
49'Sic
"wk
RECEIVED
e PLUMBING
EUREAU
(A
I, the undersigned, hereby if Xt the soil tests ep ed on this form were made by n e irc accord with the procedures and methods specified in the Wisconsin
Administrative Code, n e a ecor a an a ocation of the tests are correct to the best of my knowledge and belief.
NAMFprin TESTS WERE COMPLETED ON:
AD DR ~ CERTIFICATION NUMBER: PHONE Nl1MBER(optional):~
CIGNNATURE:
-
DISTRIBUTION: Origin,,) and one opy to Local -%ulhority, Property Owner and &A Tester.
DILHR-S1313-6395 (R. 02'82) ?
ST.
WISCONS NNTY
ZONING OFFICE
796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
July 21, 1986
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the Ed Halkoski propery, located at
the NWT of the NE114 of Section 31, T31N-R18W, Town of Star Prairie,
St, Croix County, revealed suitable soils at a depth of 4.6 feet,
below which seasonable high ground water was noted.
This site should be suitable for an in ground pressure system.
Should you have any questions, please feel free to contact this
office
Sincer ly, t
Thomas C. Nelson
Assistant Zoning Administrator
86 t 15
TCN/mj
j(jC 2 8 1986
ALUA4,9//VG
BU~~
A
State of Wisconsin ` Department of Industry, Labor and Human Relations
SAFETY & U N
ISION
d 1
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1",lit L>': 11"4{tssc{, i 3
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DILHR-SBD-6423 (N. 04181)
DEPARTMENT OF REPORT ON SOIL BORINGS ANDaFE~TOf & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 P.O. BOX 76
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION::./ / SECTION: TO NSHIP/MUfU}EFPA~IiY: LOT O.:BLK. ' SUBDIVI ON NAME:
j/4',& 1/4 ~T N/R t (or
IICQUNT OW S/BU S NAME: tfm ADDRESS: ~ 11
)
USE DATES OBSERVATION MADE
NO,BEDRMB.: COMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑ New X Replace
RATING: S= Site suitable for system U= Site unsuitable for system _
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTE -IN- L OLDING TANK: RECOMMENDED SYSTE :(opti al)
❑S ®u ®S ❑u ; ZS ❑u EIS ®u aS u
If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHFI9, OBSERVED ST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
/
B-
r - ~
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 1AIGIIES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PE O PER INCH
P,
P-3
/
P-1:5L 5's
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 ELEVA !IO 9__-29
I. }
3
w E
~ u>•tia(; d~.~ l1~u Via/ _ ~ I 1,4
I
l I
I
3
J-1 -
r i S
E ^
E
I ~ r
;
.
I, the undersigned, hereby tests ep d on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Ad Ze
ministrative Code, a an a ovation of the tests are correct to the best of my knowledge and belief.
NAM~(prin TESTS WERE COMPLETED ON:
_
ADDRESS: t
CERTIFICATION NU BER: PHONE NUMBER (optional):
C IGNATURE
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
G;
JS FOL , FORM 115 - SB -
To i it test, your rep
1.
2.
ALL,
6,
e
i manent:
-:emp-
-ED WITH THE
Si
1 ~
y
'lay
ST. CROIX COUNTY
WISCONSIN
r
` br + ZONING OFFICE
.r 798-2239 (HAMMOND)
425-8383 (RIVER FALLS)
FRI HAMMOND, WI 54015
July 21, 1986
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the Ed Halkoski propery, located at
the NW-4 of the NE14 of Section 31, T31N-R18W, Town of Star Prairie,
St. Croix County, revealed suitable soils at a depth of 4.6 feet,
below which seasonable high ground water was noted.
This site should be suitable for an in ground pressure system.
Should you have any questions, please feel free to contact this
office.
S inc er ly ,
n[//•/] //J r
V , I!II,,1~ /
Thomas C. Nelson
Assistant Zoning Administrator
TCN/mj
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township ftMk%k W
NW 141 NE Z S 31 T 31 N/R 18 XRW Star Prairie St. Croix
Street Address: Subdivision: County:
Landowners Name: Mailing Address:
,Ed Halkoski Rt. 1 Somerset WI 54025
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, I
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
Signature of Applicant Date
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF This day of 19
Notary Public, State of Wisconsin
DILHR-SBD-6413 (N. 05/81) My Commission Expires:
- ' WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location NW 1/4, NE 1/4, Sec. 31 T 31 N, R 18x) W
Town Star Prairie Street Address
Lot No. , Block , Subdivision
Landowner's Name: Ed Halkoski
The application for this site is for:
❑ new construction use.
® replacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
to have one of the first five approvals guaranteed for this year. This is
number - - of those applications. (Use one of the first five
quota num ersissued to you.)
]one of the applications needing a quota number. The quota number assigned to
this application is - -
for one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
D for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department.
[....for an application on file prior to February 1, 1980.
(_]for a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is
replacing:
U a failing conventional soil absorption system.
U a holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a
conventional private sewage system, check here.n
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Nelson S1 Ure
County Official
Title Assistant Zoning Administrator Date July 21, 1986
DILHR-SBY-6158 (R 12/82)
H
z
STC - 105 r
r
a
SEPTIC TANK MAINTENANCE AGREEMENT ~y+
• o
St. Croix County z
ry
a
OWNER/B -E?,,n u 0) b L.KbS k1 5, NILDIeED LKaSK, M
ROUTE/BOX NUMBER f GX 16f--X Fire Number 7/
.CITY/STATE -S9M e-,C&-7- ~FJIS ZIP X25'
PROPERTY LOCATION: I(W 14, & ;y, Section % T 31 N R/_W,
Town of 5VAR ~+QF~ r fLl , St. Croix County,
Subdivision Lot number
I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic•tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
I/WE, the undersigned, have read the above requirements and agree z
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIG
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.
• t
k
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 K Pk
Location of Property Ji.J 1% AJ L.:' 3, Section j , T_N-R - W
Township 9- f. R f L
Mailing Addresses 1 K (p C4 -
Address of Site /c T',
Subdivision Name Al 411) C=
..Lot Number A) n Al y
Previous Owner of Property 1,6 e3 A t G- ~ /YI A-( (\J
Total Size of Parcel L-2- f9 c2,-r
Date Parcel was Created C/
Are all corners and lot lines identifiable?_ Yes No
Is this property being developed for resale (spec house) Yes No
Volume 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) eeAti.6y that at t statements on this Bohm ahe tAue to the best o6 my (ouk)
knowtedg e; that I (we) am (ane) the owneA(s) o6 the pupe ty des cA bed in this
in6o,cmation 6o4m, by vi tue o6 a waAAanty deed neconded in the 044ice of the
County Reg.i step o4 Deeds as Document No. 4,2-; and that I (we) pne~s en tey
own the pnopos ed site bon the sewage digs os s yz em (on I (we) have obtained an
easement, to nun with the above de c i.bed pupe tq, bon the eonstAucti.on o6 said
system, and the same has been duty keemded in the 066ice o6 the County Regi,6ten o4
Deeds, as Document No.
SIGNATURE OF`.OWNER SIGNA URE OF CO-OWNER (IF APPLICABLE)
DAT SIGNED DATE SIGNED
L