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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
-R 0 y /
OWNER r,aa TOWNSHIP ~ SEC. (F' TaS! N-RL5 nW
ADDRESS( (Z7 S ST. CROIX COUNTY, WISCONSIN
R a.S o rr _ ~~yC~ /
SUBDIVISION GS LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
0& q,
(No 55.1.J we" :PC 14
X 70
rz~ 1 "E I Y. loon'
Scm~~ Vq"•_- 0 .
` 1 loa/a9 /Q~ ~ ~ I
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Ndus Jar
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used -Pnla,~ 7c-i
Elevation of vertical reference point: /DOo O " Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: fd 2
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: /0 3, Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, O 70 feet
From nearest-property line Front,O Side 1 Rear, O
/60 feet
Number of feet from: well building:
30 y'
(Include this information of the above lot dimensions to✓ E i~U
P plan)( 2 reference dimennsions to SE tic tank)
~
SEE REVERSE SIDE
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: ~og~akiou o / Trench:
Width: led' Length: 3 6 Number of Lines: Area Built: (0 VV-it?7
Fill depth to top of pipe: 41D
i
Number of feet from nearest property line: Front, O Side, O Rear, ht
Number of feet from well: /(-.O
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
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969. . BUREAU OF PLUMBING
MADISON. WI 53707
l.D.Number:
CONVENTIONAL ❑ALTERNATIVE StatePland)
(1f assigne
❑ Holding Tank El In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: IN EC ION DAT
Greg Breaul.t 207 - 12th St. Hudson WI 54016
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
NE SW Section 18, T28N-R19W Town of Troy, Lot #1
Name of Plumber: MP/MPRSW No. County: Sanitary Permit Number:
Strohbeen I5432 St. Croix 88397
SEPTIC TANK/HOLDING TANK: -
MANUFACTUR R: * LIQUID CAPACI TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
IX I
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER YES ❑ NO ❑ YES ❑ NO
li]
't ALARM: NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
00.7 FEET FROM LINE AIR INLET_
YES ONO OYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: ILIOUID CAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
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 moistureat 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:
BED/TRENCH WIDTH: ILENGTH: IN O.OF IDISTR PIPE SPACING COVE JINSIDE DIA #PITS LIQUID
/ y/ TREE, p/1Q5HE5 M T I PIT DEPTH:
DIMENSIONS k✓j(/f~ (,rrW'
GRAVEL DEPTH FILL DEPTH DISTR. PI PF DISTR. PIPE DISTR. PIPJMATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
2
BELOW PIPES. ABOVE COVER ELEV. INLET. ELEV. END: PIPES LINE. AIR IN
JLET
d LS ^ FEET FROM ~/Q /~Q
NEAREST------p-
&
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-
OYES ONO meets the criteria for medium sand. TIONS MEASURED.
OIL COVER TEXTURE PERMANENT MARKERS j..1EHV11TI.1 WELLS
OYES ONO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED
_J I J
DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED
CENTER: EDGES.
OYES ONO OYES ONO OYES 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 OISTHIBU TION PIPE MATERIAL & MARKING
ELEV.. ELEV.: DIA.: ELEV.: PIPES. DIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE yOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
OYES ONO OYES NO
COMMENTS: PERMANENT MARKERS: OBSE RVATION WELLS: NUMBER OF PROPERTY JWELL BUILDING:
FEET FROM LINE:
OYES ONO DYES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SI A U TITLE
DILHR SBD 6710 (R. 01/82)
I
EZ SANITARY PERMIT APPLICATION CouN
9~HR In accord with ILHR 83.05, Wis. Adm. Code
STATE SA ITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN II.D./NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application.
PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
'/4 )1/4,S T.8 ,N,R/ E(or
-It & PPROPERT11 OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
2`I'h /
(A I, J
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK
Ej VILLAGE :
11. TYPE OF BUILDING OR USE SERVED: - D' yD 7,1
Number of Bedrooms if 1 or 2 Family ORE] Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. M
L,,.V 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. 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 X Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank COO 14,44 +s ❑ ❑ ❑ ❑
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.
Plumber's Name (Print): Plu ber's Signature: (No S s) MP/MPRSW No.: Business Phone Number:
heel"
//77?- S'S/3 Z- 2 2
Plumber' Address (Street, City, State, Zip Code): Name of Designer:
VII . SOIL TEST INFORMATION
Certifi d Soi Tester (CST) N me CST #
er- ld ri`C `i~ 02-14l82-
CST's ADDRESS (Street ity, State, Zip Code)' > Phone Number:
0 Not - 14,0
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sani ary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
INh
Approved ❑ Owner Given Initial / ®d SyLpharge-A t e
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
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 221o ~ years;
6. if you have questions concerning your private sewage syster:-=, contact your local :ode 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;
II. 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;
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 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 Grounddter-
included the creation of surcharges (lees) for a number of regulated practices which Wiscorisln's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water tha' buried treasure
is used in your building is returned to the groundwater through your soil absorption \ o
system or the disposal site used by your holding tank pumper.
The monies collectec' through these sir0arges are credited to the groundwater fund adminis-
tered by the Department of Natural R,~sources. These funds are used for monitoring ground- t
IvVlater, gr our._lwater contamination intestigations and establishment of standards, Groundwater,
is worth protecting.
SBD-6398 ;R.03/86)
Lld
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
Location of Property Section , T N-R
Township #1(
Mailing Address =1~ L 1-Ji -T-
4L 4-IT -
Address of Site K~ 4, f 'G
Subdivision Name Spa .l ' r~ r
Lot Number
Previous Owner of Property 1/)l s ~
Total Size of Parcel r i
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes X 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
1 (We) cehti,6y that a.tt Statement6 on thin bonm ane tAue to the best o6 my (oun)
knowledge; that I (we) am (ane) the owneA(4) ob the ptcopexty de,schibed in thi6
in6okmati,on bosun, by viAtue ob a way anty deed tcecokded in the 066ice o6 the
County Regi6teA 06 Deeds as Document No. 6 and that I (We) pke~s en t2y
own the puposed site bolt the sewage dizoos yS tem• (ac I (we) have obtained an
easement, to tcun with the above d"ck bed p>topenty, bot[, the conathucti.on ob said
by tem, and the .dame has been duty Aeco,%ded in the 066ice ob the County Reg.c.6teA ob
Heeds, as Document No./~~) .
Bc~t I eCZ, L L
ci A- I cul c"
SIGNATURE 1t OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED )
z
H
• a
ST C- 105 r
r
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H
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
d
a
OWNER/BUYER
ROUTE/BOX NUMBER cR61)~1~'Tf ,S Fire Number
.CITY/STATEZIP
PROPERTY LOCATION:,j~14, Section, T N, R_n
Town of , St. Croix County,
Subdivision, Lot number.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank 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
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
menu 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
ac~
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS 1115, P.O. BOX 7969
HUMAN RELATIONS ` MADISON, WI 53707
(H63.090) & Chapter 145.045) Ld /
dJ~ ' , ~~ION--. TOWNSHIP/M4ihff8tf'14tf~Y: OT NO.: BLK. NO.: SUM77 10154 NAME:
T / / d N/R /yE' to 7,&_r es ojA)
COUNTY: OWNER' S NAME: MAILING ADDRESS:
L~ND,,ryE'~l~'~ 2iT• 6 o5r. CediX 3WE- Z GU1,11,f` ffvDJ'v~ 41 /s ,
USE DATES OBSERVATIONS MADE
NO. BEDRMS. CO ER AL DE SC
esidence - - DESCRIPTIONS: IPERC A ESTS:
3 )QNew Replace I _ /
~f'
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTI NAL: MOUND: IN-GRUU- ND-RESSURR S S EM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
®$❑U S❑U RS DU ❑Sa ❑SEJU e'ovc4r_1VT0ur1 JAA, o4T~►~
' Prt~~u.auwi esis ard'iv~~ requvdo r)SU'AkP.4.TFt. LF'loodplain, an y portion the tested area is in the under s,H63.09151(b), indicate: indicate Floodplain
elevation:
PROFILE DESCRIPTIONS pv J-o"isiA ,
BORING TdfA-L P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / 10.0 90,3p' ~a a /.o • v •,c• s/, is • isN. S1 Ac 2' o'• w..
O ° P .lu v cs 15
B-f O•or 9(O Orr O•o, ' ~itv s~, ~,~3•~sd•f~, iS' ~y ti(x.
• -ga. yam' r'W Of
3 q p' , y 7' E,1►• I,W , . 83' d;.u. %4N , J WV SO, / /lo y .
B- 9G . F0 o s s.s 7.4N 6eer es . ,
y /,0' 81. S//, /.o 6A P- m, .1 -0
B- /0'S 9(0.72, /0. S s. t fiUt -10-- 0. - &,.,17 • T N CS .
/ • 0 A S ' 1,e- 74v 21.4 .
B_
PERCOLATION TESTS
WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
4BER
AFTERSWELLING INTERVAL-MIN. PER1002 PER INCH
1 e r 1005
TE / .e tS
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 ELEVATION
:
eO Z a hp- 1 - - -
~ rt
This test site APPROVED ` ' - - -
h for a conventional septic system.-.- I_.. ; ~ _ _ ~ _ ~ ! _
tN
v ! ' _ . i : r -fit ~ • ~
1 aPOK 1 t _f. _Z~`~...~
:
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{
I, the undersigned, hereby certify that the soil tests reported on this form weretade by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME print : TESTS WERE COMPLETED ON:
-NOWSITE SEPTIC PLLNrVft1C0.----- - 140 y '70- /9000
ADDRESS: 4; iOWEII: 40., ROBERT19
HON, VAS 54016 CERTIFICATION NUMBER: PHONE NUMBERIoptional
ULBCHT P2, 3P6 SO/
MINN. INSTALLER & DESIGNER LIC. NO. 00663 CST SI NATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
'phOHG yD2 ~ ~ ~ow yr ~a.~ # ~ ~
pGl (NOS4,a1~ li'Pipe, s~T V"'T. .
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