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HomeMy WebLinkAbout040-1004-40-000 W6 - • Q N() - JOct4- qo _ ood , 7 S To LAitcr R Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ATOWNSHIP SEC. Z T Z9 N-R I W ADDRESS 3 bo S 2~U s~l~E' T G ST. CROIX COUNTY, WISCONSIN ali d (P SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 j 'Z ~I 9)SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 0~ S -4~ INDICATE NORTH ARROW . Top of Cv~S(3e BENCHMARK: Describe the vertical reference point used p *6- Z ys- /L_ Elevation of vertical reference point: Q Proposed slope at site: ~'ESc,~ l0a2~ - SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: ~l S 0 Number of feet from nearest Road: Front,© Side,O Rear, 0 feet 2 IDEST" From nearest property line Front 10Side ,ORear, 0 feet ND l Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) t f PUMP CHAMBER Manufacturer: Liqu apacity: Pump Model: Pump/Si n Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch el ation: Gallons per cycle: Alarm Manuf urer: Alarm Switch Type: Number f feet from nearest property line: Front, O Side, O Rear , Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM -re6V ~ ax W z 77 Bed: Trench: Width: 'S Length: Number of Lines: Z Area Built: -~v Fill depth to top of pipe: Lt9EJT Number of feet from nearest property line: Front, O Side, Rear,0 Pt. Z Number of feet from well: ' Number of feet from building: (O~ (Include distances,on plot plan). SEEPAGE PIT Size:., Number of pits: ameter: Liquid depth: Bottoja~i seepage pit elevation: Area Built: Has either a drop b or distribution box O been used on any of bSve soil absorbtion sy s? (Check (one). HOLDIN ANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inl Number eet from nearest property line: Front, O Side, O Rear, O Ft. 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: HOME. SITE SEPTIC PEUMO NG CO. RT. 3 D'NEIL RD.; HUDSON, WIS. 54016 ROBERT ULBRICHT 3/84:mj ! JIS MASTER PLUMBER LIC. N0.3307 MAR& VOW iis]'ALLER &DESIGNER LIC. N0. 006663 .4s Sul4r ,DLo r J CtgAA) P~ ooF MAW~ ! y. ~pSuc.fTFO,,y~,.a wrV^- ~VE~T 7+~DE'• C•T r ~ S got JLA-r'15 f~ CIEVAVOA) C 'Yo - go3'~ Pot- FlilS`oAM T~f'E.uGti~$ 36 ~r T-o-r, 367.5 RS coNSTeu~Ttu ~o gEav gar. Rtf. 7T- lsr T pkave od of la ----------~'s,---------. ✓ Yyl ~,1 ~~~~s - - 93,60 T~~ of ~r~e BOO. PQ~c+sT 9to73 ~S t is pK s3 PPa~E b, 13. I -of J w es r [-o T L . i :FL.0 "--30 114fo oR EN G,;.v .5 f rte" all F,ros f Rr-GDAoEo f~'am NorE: ~ Er HOMESITE SEPTIC PLUMB1Nti (Q ?A"''~' ~ of RT. 3 O'NEIt RD., HUDSON, WIS. 540JO r '/IS. MASTER PLOUBMKR LIIC.INO. 3307 MARS :NS'TALLER & DESIGNER LIC. NO, 0066a t G f I O t Tv A00117 UTuity L1 3E D T f QoK y" G •s vENT O 1 rj Iy// {V~ LrV ~ E I r / ~uFc ~c 144)F ..-1 g ,r SILAGE' " sP,~cE pooTE of cop~v VAl y~ 0 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 R2CONVENTIONAL DALTERNATIVE State Plan I.D. Number: El Holding Tank El In-Ground Pressure El mound (11 86 assigned) ned) 1-3 COMMERCIAL NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: pp~~ A T & T Inc. 300 S. Riverside Plaza Chicago. IL 60636 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. NW SW Section 2 T28N-R19W Town of Troy Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: R r 88431 St. Croix 88431 , Ulbricht i SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LAB L LOCKING COVER ~j / P VIDED: PROVIDED: / - ! ,_5 YES ENO DYES O BEDDING: VENT OIA.: VENT MAT (4 HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: LINE / i AIR INLET FEET DYES NO DYES ENO INEARESOM DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ENO DYES ENO DYES ENO GALLONS PER CYCLE: TUMPANDCONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE, AIR INLET PUMP ON AND OFF) DYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER 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: WIDTH: JLENJH'/ O. OF JDISTR. PIPE SPACINGCOVER J INSIUE DI A#PITSLIQUID BED/TRENCH 7THE NCH E& / MAT IAL: PIT DEPTH DIMENSIONS Z- GRAVEL DEPTH FILL DEPTH DI R PIP DISTR. PIPE DISTR. PIPE MATERIAL: NO. DIS NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES. ABOVE COVER: EyLT ELEVNDj 7~ C? PIPES. FEET FROM LI" / A~ ~ L~T. e r / V NEAREST ► -V l9 4~+ MOUND SYSTEM: 110 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- DYES ENO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS OBSERVATION WELLS DYES ENO EYES ENO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED. CENTER. EDGES. DYES ENO DYES ENO DYES ENO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA.. ELEV.. PIPES CIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ENO DYES ENO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING: FEET FROM LINE: DYES ENO DYES ENO NEAREST Sketch System on R ain in county file for audit. Reverse Side. SIGNAT / TITLE DILHR SBD 6710 (R. 01/82) 1 EzSANITARY PERMIT APPLICATION COUNTY - IX DILHR In accord with ILHR 83.05, Wis. Adm. Code sT G RQ owns STATE SANITA3 RY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN (.D. UMBER 8% x 11 inches in size. 8%0 9~10 ,3 -See reverse side for instructions for completing this application. 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE ❑ YES V%.J NO PROPERTY OWNER PROPERTY LOCATION ~'T~~ ' ~IUG W %4S Z T24 N,R117 E(or P OPERTY OW R'S MAILING ADDRESS 1' w LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY, STATE ZIP CODE PHONE NUMBER CITY h!AKE Gti/~ G ZLL • 1C b 606 12 55 y-75s F-I VILLAGE : TRG y NEAREST ROAD, o WEX RDr 11. TYPE OF BUILDING OR USE SERVED: TO wtp - N O De' Number of Bedrooms if 1 or 2 Family OR ® Public (Specify): Ta(,•~E/>~ Q L~~ 111. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. Replacement c. ❑ Replacement of d. ❑ 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. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ See a e Bed b. N 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): p 33 a Feet Private ❑ Joint El Public r VI. TANK CAPACITY in allons Total #of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank j a .'r 2S Lift Pump Tank/Si hon Chamber N E_ CLA J" ❑ ❑ ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 12a&V" Z l b1~~'~ti T' 330 7 715- Plumber's Address (Street, City, State, Zip Code): Name of Designer: VT-3 t{uD~o~ 14)/,5 Sya{v T` Vlll. SOIL TEST INFORMATION Certified Soil Tester (CST) Name HOMESITE SEPTIC ftU(VlbINb . CST # RT. 3 O'NEIL RD.: HUDSON, WIS. 54016 Z CST's ADDRESS (Street, City, State, Zip Code) ROBERT HI:8R!GIl-T--_ Phone Number: WIS. MASTER PLUMBER, L,C. NO. 3307 M.P.R.S MINN. IN TALLER & DESIGNER LIC. NO. 006631 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S ary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination fe-6- ~ J~ X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any"new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a iicensec pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local cocks 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; !l. Type of building or use served: If public is checked, indicate. ',ype 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; 111. 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 8Y2 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 Groundwater -~1- included the creation of surcharges (fees) for a number of regulated practices which Wiscorisin`S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure is used in your building is returned to the groundwater through your soil absorption } system or the disposal site used byyaur holding tank pumper. The s conies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural R=esources. These funds are used for mon loring o round- water, groundwater contamination investigations and establishment of standa dv. it's worth protecting. SBD-6398 (R.03/86) REPORT ON SOIL BORINGS & PERCOLATION TESTS 115 PLOT PLAN Project I.D. LEGEND HOWSIIE SEPTIC PLUMBING CQ IT. i O'NEIL RD., HUDSON, yt, S,pu Ba ekh o e Fits 1 s x %sr.NG gp,TpE ROBERT ULIRICHT 6/Eri1 r/ 4w5 03. MASTER PLUMBER LIC. N0.3317 M.P.Rt X Perc Locations MINN. INSTALLER & gESIGNER LIC N0. gp Existing Well C.S.T. 2482 Vertical Reference Point Top of WAS Bflf- 6QECU P&OAJE F~CO- ROX # Zys'-/z Elevation of Vertical Reference Point . /04 0, fT -Lot Line I I SCALE -MAER RIO, 'Nw G0fi pR%vew~ C oRMER , p 8 q;L- y yap K° J 6XiSTi.U(T i` _ 37 I 4. T T. veef. .t3~D6 NPE:A- _ ,t3~tt"Poo W 7 j yo I ~ FROPOSEP E f(SnA)G- $ySTt~"I ppIVY [ TD QE XEHOfJE,D~ I TED ;A A ftA i CC x A FAIem FiELID.5 8 cfrc/our 4CAX ( 00Ep- )00 kGpES) \ o l~ cow~ovup, Sv,PiPavuDrtiU-- Ua>7~ R CROPS ~ ~rOrc'~!2 S EaW z i p ~J Q 41i 0 0. ~ o ~ ~ ~ v lk" Oc, "r 00 C o 0 40 17 E f ~ . °o C, ku \ ~rti Tom- 0 v oL a- CL- Ca Fo i r - LLS ~a'-~' L! (k iu N Old 1 0.° F- w + 0, -x 1! N- O w v di 44 -A ti a14 i N Q rl O Z N °vV 3oa 8608813 RECEIVW Cl1 ° 1986 Nov 03 % > p Mi.UMBING SECTION ! 1.1 ~ v • PROJECT INDEX SHEET OWNER : .3v° Sp ~i'UE~Q S/~E ~L~~.q- Gh/G~f fQ ZLL . Co D G, O G ADDRESS: SITE LOCATION: T~PD'/ ST, Ek0%X/y• Alto '/y 5k) %y See, z, T..Ze.V Gtr PROJECT DESCRIPTION: l PuQL- ; SyS'Tj'M . ~u ~z%srrv~ T 31 ToWek-,44404 - 1340&. h4s ~~~a ADD~~ ocl7`o 3 ~PE~yD1aELI&D • 'Vew Pd~rSr'4aD.rq 6cJ1-ek T"o s-- 6ec t o y•~ (Ve u0E// ooe ru~r ~ se e vices max: sTS -scwf~Y~ . ~S y ~,u rrr S No ri/s , 4A /L -ACS kr#srxs PAGE 1. PT,OT PT,AN VTE`aS RtGT 2. Mt~ff _ ° SYSTEM PT,Ai1 TdIE4lS PAG ~~a 3. PIP P!, T _ C,Q OS f SGT/O.J /oG,~tls . ' l RECEIVE CJt V INN- v WIT" PLUMBER: r.., ITE EVALUATER or DESIGNER HOMESITE SEPTIC P}{iB1G CO. W. 3 OWEIL RD., HUDSON, WIS. 54016 HOMESITE SEPTIC PLUMBING CO. ROBERT ULBRICH4 RT. 3 OWEIL RD., HUDSON, WIS. 54016 WIS. MASTER PLUMBER I.W. NO. 3307 MARS. ROBERT ULBRICK MINN. INSTALLER & DESIGNER LIC. NO. 00663 WIS. MASTER PLUMBER LW. NO. 3307 M.P.R.& MINN. INSTALLER & DESIGNER LIC. NO. 0060 DATE: S IGNATURE 8 6 0 8 8 1 3 Q6&GA(3SoRPno So~~s -r~sT~a r4R~ c-G~4SS . F~~e C©.vVf 7AVA1,f/ ""Aj V xi kt au ~ fir: v sq. Fr 330 3 y0 sq. ~T, 2f fl 11'21.v Z x T~~k C~+Pi4-c/ry 9 2a P,0&1,a yl;.vI.Af U,N► 7 , c,yAc 900 66/o0 /D D o 5so . Project I.D. fj,,' bie 2- PLOT PLAN /~UOJO~J ~ iS. LEGEn Backhoe, Fits A aelrlw6- 9,04A-- X = Pere Locations / &1,60-►ruws Existing Well Vertical Reference Point TOP of Wis. DECO CrQFfv ~ Ekp-aox levation of Vertical Reference Point . /OD . Q fr. Lot RECEIVED r 0 -'1986 r3tU RING SECTION SCAM: 'Nw ~ CoR R DR%~ 868 81 3 1,.;& 86 . yo _ 37- A T ' T .81-46- ,~RephceHE.ut V~ It'PCA- 1-. ~ / F/cee ~t31i.~ I~ 4,s'~ SS y ~~Pa fcy -pQa p4eD `~~'E l l1/~ 11D 9 .3 , PR i1V ' To 8~ ~'e~evEp~ f ~NED is lqy FARM FleL,05 oaf goo RcREs 1 j---- _ . , _ cyc/ovx- rcAz r ane R CR0p4 J 91 / q 40a/00,0,0, Sv,~~cvyo~ ~ )10"A. HNf 3 .f1 • "01- a-20 4 T . Cam ~w~' T~o.~s 407- /Y t Y 5 w y S.tc. Z , T21 N 4Ifk) W6- f 0O J /~`J/V~~ rV\ U G L1~ /V7~. . J~ lv^1 vJ O w o h RECEIVED NOV 0 x;1986 mi,W RING SECTION 86488.3 rXP1'cAZ. 1?W 807t-- TAP -~~.tEs v Fresh Air Inlets And Observation Pipe d h 0 Approved Vent Cap i•~ 12" Above Final Grade /~jPd~OSEG7 F~~i! L 4" Cast Iron N2 " Above Pipe - To Final Grade Vent Pipe ` Synthetic Covering Min. 2Is Aggregate Over Pipe Distribution : I- - - Tee Pipe o 0 0 0 o , /Z" Aggregate o Perforated Pie Below ~eJQ so,-t- 7esr Beneath Pipe p f~ooM p~ 3H pGk o Coupling Terminating At c14 Bottom Of System 107 • . DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND P.O. BOX 7969 PERCOLATION TESTS (115) HUMAN RELATIONS (H63.090) & Chapter 145.045) MADISON, WI 53707 LOCATION: SECTION: TOWNSHIP/may; L OTNO.:BLK. NO.: SUBDIVISIO N N A M E: ~W V4 ~/a Z /T28 N/R i9 E to ?Roy A4,071 of ,fC,PE- COUNTY: OWNER'S VTrr 7TT"F 1l MAILING ADDRESS:.Sif.T> ST•GRO/X A.T. t7- CcJNMuNGi'~fiotl COQ C/p R-SFS}IIou~~ - A•T ?TENgiu~E~oS P ~2s Gi>. G,~ltrJQEAJGt~ s-F ~4p It_ To~J 4j is. S4,e USE ERCIAL DESCRIPTION: DATES OBSERVATIONS MADE NO. BEDRMS.: CAOMM PRO I ❑Res' T• T TO J~R LE DESCRIPTIONS: PER OLATION TESTS: ❑New ,Replace. (Oe7~ ~ _ d'(o DC~I• ~ y- 5 cAt~o..ut a rk p La yeas , I fc ~ a ~E~t~ilCiN lr A- iVF y DR rN RATING: S= Site suitable for system U= Site unsuitable for system ' CONVENTIONAL: MOUND: IN-G((R:~OI1UND-PRESSURE: SYSTEM-IN-~FttILLHOLDING TANK: RECOMMENDED SYSTEM:T'onal) ©S ❑U S ❑U l3~S ❑U ❑ L'~JU ❑S ~V 7"PCQr_lE.f oNCy iF (b )VLCAdio.)ri~ DUE TO V1} ,`E p ?IAJ - 74AJ i e M p i If Percolation Tests are NOT required DESIGN RATE: If an ~+q C6~4 SS any portion of the tested area is in the under s.H63.09(5)(b), indicate: 7 Floodplain, indicate Floodplain elevation: G PROFILE DESCRIPTIONS NJ ZECiA4r41, F+. BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) y, . 33 vr%RRAI, 3 w s.~+.►/ poeTS o f B- 9(.7( o 9 D Teti . s. s: 0' Z"AED VW = $N• moo. s. s,/ /.d'$.r• S,' X~u ac B-2 9. o ~7 yy` - > 9. .7,0'M ° x. B-~ / 5 v ` C'oAPSE A67,0 f~s / f O0-,ilX 7f T ,-,Il 4avnr B- ,9 9~2zI > Ru-~r /,S'r.}a s,, yq• H B-5 F5 7 7 d ' 7 CEO -B SI ` cvI TVA f fj µots 001?mAL RC`STRI`C.}iorJ of- BSi/. S' B..j • s/ *4. $ . 5v~2f,IL~ c~/~t/ilT<o.115 ~f~!K PERCOLATION TESTS `41 TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES W NUMBER IN: AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER10 3 PER INCH 4G•8 / a 2 S )b P `b /0 & /_11146 ti. P t 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- N 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 y of land slope. ?2 /f ffeef4ye- SYSTEM ELEVATION PI 'AC-.s _ Skill f _"l lea i 7th,y ~E .r........ ( 1 -1-`o G • • - I _t _iok &r L12 1E S - - - 114 I, the undersigned, hereby certify that the soil tests reported on this form r ord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the t corre to th- my knowledge and belief. NAME (print): STS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. j jg ~~o D' C • Z y_. ~y0G f S _ ADDRESS: 1117 MSOR ~S 86 RTiIFICAI'N NUMBER: PH'NE NUMB ptional►: O ROBERT ULBRIGH4 VAS. MASTER PLUMBER 6~G. NO. 3307 M.12 WW INSTALLER & DESIGNER L►C. N0.006G3 CS IGNATUR d DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - JCTIONS FOR C~--F~ 115 rate soil t€ 1. _ 2 indicate 4 L.Y IF ALL, ,t 7. BE FILE[ rs I - ss -:RS W.. r u _oarn . Tr) H z H a STC - 105 r r a SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 0 z OWNER/OfffEi~ t~ ROUTE/BOX NUMBER Fire Number .CITY/STATE //uosatl, ~t S ` ZIP 1 PROPERTY LOCATION: N(t) it, Section Z T a N, R W, Town of 7 40 , St. Croix County, / ~etg_ mot 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. H 0 E 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. ? y SIGNED \O~ 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. 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X. . v,V/C' ,*T1ov s ~ Owner of Property c ~ p~ Location of Property Section Z Ted" N-R 6 W Township Mailing Address Address of Site Subdivision Name Lot Number l_ Previous Owner of property Total Size of Parcel Date. Parcel was Created Are all corners and lot lines identifiable? Yes No Is this 2pr?operty being developed for resale (spec house) ? Yes No Volume ✓_J ,4 and Page Number 2 ? 0 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) cvLti.6y that att statements on this 6otm ahe tAue to the beat o6 my (auk) k.nowtedg e; that I (we) am (aAe) the owneA (b) o6 the ptcopext y described in this .in6oAmation 6oAm, by vi tue o6 a waAAanty deed Aecotded in the 06j,ice o6 the County Regi,6teA o6 Deeds as Document No. ? ,3 D ; and that I (We) pAesentty own the ptopob ed site 6oA the sewage digs pob "s yTs em (o t I (we) have obtained an easement, to nun with the above desni.bed ptopehty, Got the conatAuction o6 said .system, and the same has been duty seconded in the 046,ice o6 the County RegisteA o6 Deeds, as Document No. A, &4c SIGNATURE OF 0 R SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED