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014-1012-95-000
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N nv v I ~ I N CD N C) p o p N L O a I~, O ti REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM SanitvLy PeAmit AP74 State Septic _ NAME 7own6 h,LSt. Ctcoix County Location Sectti.on Lot # Subdi,,,ision SEPTIC TANK Size ga..-o n Numb etc o6 co mpatctment6 Distance 6hom: Wett Building 1,20 .6.2ope HighwateA PUMPING CHAMBER Size gatton&- .P_ump Manu6actuttetc Modet Numbers HOLDING TANK Size gattont6 Numbetc o6 Compatctments Pumpetc Atatcm System Di.stance 64om: wett Building 120 stope Highwaten ABSORPTION SITE Bed Ttcench DiAtance 6tcom: wett Building 1.20 ~stope Highwaxetc ABSORPTION SITE DIMENSIONS Width o6 znench ~t Requtitced area 6t Length o6 each tine 6t Depth o6 tcock below ti e in Numbetc o6 ti-nets Depth o6 tc.och ovet ti e in Total tength o6 Zines 6t Depth o6 tite be.2ow gtcade in Di6tance between tines 6t Stope ob trench in. pen 100 6t r To,tat absotcpt.Lon atcea ~t Type o6 Covetc: Papetc otc 6ttcaw PIT DIMENSIONS Numb etc o6 pits Gtcavet atcound pits yeas Outside diametetc 6t Depth betow intex Totat ab6 otcption atcea 6Z Atcea tce.quiA.ed 6t INSPECTED BY TITLE APPROVED DATE 198 REJECTED DATE 198 REASON FOR REJECTION REPORT ON INSPECTION OF SANITARY PERMIT # 1,3 (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection me, ress, License/NO. o ns a ~Ing Plumber Time of Inspection 3 INSTALLATION CONSIST OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System B ermanen reference Point) Describe: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: M DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? E ]YES ❑ NO 8 HOLDING TANK: Manufacturer o gallons construction depth to the cover ft; If septic tank is being used are baffles removed? YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ N0; Wired? ❑ YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth.; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095 N.0 /8 Signature of Inspector: f-H:.115 Rev.9/78 / REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES vG{~ c4 P.O. BOX 309, MADISON, WISCONSIN 53701 ' 119, r LOCATION Section T.VN, (or) W, Township or Municipality Lot No. , Block No. County Subdivision Name Owner's/Buyers Name: Mailing Address: 6 TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT -ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS'a, PE~OLATION TESTS 16-12-72-- SOIL MAP SHEET NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL RATE BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- / L E'er oec P,3 t < <i 4 t= P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST- IF OBSERVED IN INCHES B- 2.. S<~ 3 .sue B_ Al, f A2 YB- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soi areas.) Indicate on the p; 1n the0cation and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy A Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. E , . t 3 a E s y a. klev F a I, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes.are correct to the best of my knowledge and bell G Name (print) Certification No. Address ' G cg - ell Z-2 z, ,Name of installer if known w Copy A - Local Authority CST Signature i PLB State and County State Permit #67 Permit Application County Per it # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Cc 6 37 7 C 61- 1411' B. LOCA ION: QomL,/ Section , T7/ N, R /te a) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township ro Aes~t C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family V Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY 6QD Total gallons No. of tanks / HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete ✓ Poured-in-Place Steel Fiberglass Other (specify) New Installation t~ Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate - Total Absorb Area sq. ft. New Replacement Alternate (Specify) Seepage Trench: ✓ No. of Lineal Ft. IS P Width - Depth__~__IV& LTile depth (top)_2_4L No. of Trenches Seepage Bed: Length SN' Width d® Depth ~ Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land- / '7to Sb t i. Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: 1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME fin 1_0 C.S.T. # and other information obtained from Vvle caner h" Plumber's Signature ~ PRSW# v_7 3 Phone # Zsv(j Plumber's Address L ^ Vol PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. a E r~ (o~S r 3 E 3S D~ 0f E s ~W. e a m e _yr,'t U i Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application v7 Feces Paid: State,_1$, "'i County to 7 - Permit Issued/ eR ected (date) 7-o`2f~ d'd Issuing Agent Name Inspection YesA_No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 o )NoCD 'I33 0a, C C) 3 CD (D T d A i 3 0 -4 (D z ° o w c 3 0 O 3 00 'r, 1, CD O A C 7 CD O .Z1 51 N C-D (p ry \ 1 N N N ZZ O. O' `~G O CO O O O (D Q 7 N D Ut G O O 0)- OOD C /D W! O CD A'+ 3 W p C r OD O c ~ w N N M I v v,-GD ~o a co N j y W a w it' Q N it 3 O W 0 ~ o o c~ TVI H CD co co w n O 0 CL Z d N I 3 °w 0C to co Z r b~ SD M rt F< ~ (D W OOO? ~ Z l~l C:) 3 c cn CA (A ~ O ? O T O G O N N p O I a a N w CCD CC 90 CD O 00 CD 3 oNi N CL H r CL co z Z o o p D D o I - ~ o a d oo a ao ~ _ In CD o c ~ I w m IV H HZ I a ~ i O rW~ M CD Z ' Z A z y e on US vt C7 O 'd n A G) O m r-h O r1 zEj N Z -I O o oo v m - a rt m z Uri H. 2 p rt O cn \ z CD W A I ° ? a 0 CL (D cm CL CD m ? o m c CAD N z O. CD W o 3• j N X70 N~ 4 N CO it w y tD O ~ V Q oo N O 40 CL v I 0 0 b ,r CD A o 9 c °a 0 CL y 0 CO) O' 3 y o d 3 I 0 d o N o p co o3. m o rn A• 0-4 s _ CD S* CL CD 0 0) m o cn O m N N N Cu- Cil D R O O O O o) fD W p rn cn 3 0 H 0° °0 0 rn c v ~cn. C m cn z CD ID c~ a s m co c= D N a -D W W a 3 a o o No co CD (D W 00 O f0 w N CA p C co ao nri ' 3 IT Q CD z to . • 000 ° Z - CA CO) o m X C" CD O v c°n m N o 'O u = 7 Qo m a N 3 D1 a ( 4 CL N o Z r N O D D D O 0 o m A :3 C N C W CD -4 cn Z O ' z A O ~ A m A G 0 Z -I w ~ m s z cn c 0 y Z C 0 I o m n nN m a 3 ~ m c ?0 o a s~3 N 0 com I ~ ~o w c~OO ~ a fD V C a~3 b N O p N O ~ OO. N W O N S m C O CL m A I o m aro ~ ~ tv O p p0 ; a a ti ` Parcel 014-1012-95-000 12/02/2005 09:45 AM PAGE 1 OF 2 Alt. Parcel 6.31.15.89A 014 - TOWN OF FOREST Current XST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - SMITH, RAY H & JUDITH N RAY H & JUDITH N SMITH 2338 265TH ST CLEAR LAKE WI 54005 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description 2338 265TH ST SC 1127 CLEAR LAKE ha 16- SP 1700, WITC / 2 b~Z d l7V Legal Description: Acres: 22.500 Plat: N/A- OT AVAILABLE SEC 6 T31N R1 5W PT OF NE SW COM N 1 A COR Block/Condo Bldg: SEC 6 TH S 02 DEG W 3090.33' TH S 83 DEG W 33.18' TO WTLY R/W LN TWN RD & POB; TH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) S 01 DEG W 904.46' ALG R/W LN TH N 89 06-31 N-1 5W DEG W 1044.78' TO MEANDER LN HARMON LK. TH N 34 DEG W 333.05' ALG MEANDER LN, TH more Notes: Parcel History: Date Doc # Vol/Page Type 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/1712005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 15,000 170,000 185,000 NO PRODUCTIVE FORST LANDS G6 2.500 4,500 0 4,500 NO ENTERED BEFORE'05 CLOSE W8 18.000 39,600 0 39,600 NO Totals for 2005: General Property 4.500 19,500 170,000 189,500 Woodland 18.000 39,600 39,600 Totals for 2004: General Property 4.500 7,500 104,200 111,700 Woodland 18.000 12,600 12,600 Lottery Credit: Claim Count: 1 Certification Date: Batch 106 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 014-1012-95-000 12/02/2005 E 2 OF A 2 PAGE Legal Description: cont. N 51 DEG E 332.95' TH N 0 DEG E 305.88' TH N 83 DEG E 999.20' TO POB I Form - S T C - 104 AS BUILT St2.ITARY SYSTEM REPORT OWNER TOWNSHIP Ica r~S~ SEC. T c.L_N-R~W ADDRESS (fleor zakc ST. CROIX COUNTY, WISCONSIN SUBDIVISION I(/>/ LOT LOT SIZE ;.1 <r3 PLAN VIEW a tv. Distances and dimensions to meet requirements of II-HR 83 OicF~ C rF SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - N ,f - e (.~D e IJ r ~ p-ran e ' No, o Caroq~ 0. INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used o~ prQ f ~D~ Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: /O~Qz Number of rings used: j5' k Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side Rear, O /f0~ f feet <-From nearest-property line Front,OSide,ORear,O feet ' Number of feet from: well- SOS- , building: 30 (Include this information of the above plot plan){ 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: ~ee .S Liquid Capacity: '70 / 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, Rear, 0 Ft. 007'. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Zwo ~ A Width: 3 Length: / Number of Lines: 174 Area Built: Fill depth to top of pipe ,.20 -0i Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. ZO Number of feet from well: 50~, rn.ra. /V w e / vet Number of feet from building: 0 441, ~l~1 Q f iS /i' e (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diamete Liquid depth: Bottom of epage p ft ele ion: Area Built: Has either a drop box O or distributi n x been a on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Eleva ono bo o of tank: Elevation of inlet: Number of feet from nearest prope y Vie: JFont, O Side, O Rear, OFt. Number of feet from well. Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Z42 Z0 O Plumber on job: License Number: 3/84:mj State of Wisconsin ~ Dep yr nt ~f Industry, Labor and Human Relations August 15, 1985 SAFETY & BUILDINGS DIVISION Bureau of Plumbing 201 E. Washington Avenue P.O. Box 7969 Madison, WI 53707 Wayne Severson & Raymond Smith Route 5, Box 132 Hudson, WI 54016. w Dear Messrs. Severson & Smith: Re: July 25, 1985, DILHR Field Investigation NE,SW,26,31,15W Town of Forest, St. Croix County, WI The subject investigation was conducted for the purpose of locating, if possible, a site for a new soil absorption system. Soil profiles were evaluated in eight backhoe constructed trenches. The profile description and locations are included in this letter. It was determined that two-very different soil conditions occur on this property and that an abrupt boundary between the two conditions exists. The north half of the property has dense glacial till underlying about one foot of silt. This till is very impermeable and therefore the soils seasonally or periodically saturate to near the surface. The southern portion of the property has a medium sand'underlying the silt cap to a depth of about 54 inches where a layer of till is encountered. The till apparently decreases as one moves in a southerly direction. This area seasonally or, periodically saturates where till is present but only to about 36 inches in the overlying sand. Therefore, this area is suitable for mound soil absorption system. Two mound sites were identified. The locations with elevations are shown`on an attached sheet. One area is identified by bore holes T-1, 2 and 3. The second area by bore holes A, B and C. Representative soil profile descriptions for each area are as follows. T-1 0-4"' Very dark grayish brown (10YR 3/2) silt loam. 4-I1" Dark yellowish brown (IOYR 4/4) gritty silt loam. 11-16" Pale brown (iOYR 6/3) gritty silt loam. 16-271' Strong brown (7.5YR 4/6) gritty silt loam. 27-54°" Dark brown (7.5YR 4/4) medium sand. A Dt L.H R-Sa D-6423 (N. 04/81) v° ' r Stale of Wisconsin ~ Department of lpdustry, Labor and Human Relations Wayne Severson & Raymond Smith SAFETY & BUILDINGS DIVISION August 15, 1985 Page 2 54-6411 Brown (7.5YR 5/4) sand with few medium distinct strong brown (7.5YR 5/8) mottles. 64" Reddish brown (5YR 4/3) dense sandy loam till. Estimated seasonal or periodic saturation at 54 T-2 Similar to T-1 with mottling at 42". T-3 0-5' Dark grayish brown (10YR 3/2). silt loam. 5-1011 Dark yellowish brown (10YR 4/4) gritty silt loam. 10-141' Pale brown (10YR 6/3) gritty silt loam. 14-19"1 Strong brown (7.5YR 4/6) gritty silt loam. 19-3611 Dark brown (7.5YR 4/4) medium sand. 36-5301 Yellowish brown (10YR 5/6) medium sand with 1/2" to 1/8" dark reddish brown (5YR 3/4) dense sand bands 2" apart with common, medium distinct strong brown (7.5YR 5/8) and light brownish gray (10YR 6/2) mottles. Estimated seasonal or periodic saturation at 36". T-A, B and C These three profiles are almost identical to T-2 with seasonal or periodic saturation from 36-42". Sincerely, Edmund M. Drozd, CPSS Soil Scientist Section of Private Sewage (608) 267-9803 EMD:1529v Enc. cc: Leroy Jan.sky, Private Sewage Consultant*- District 6, Chippewa Falls Harold C. Barber, Zoning Administrator - St. Croix County Representative Paulson DILHR-SBO.6423 (N. 04/81) Pilo I A x Wisconsin Department of Inds Labor & Human Relation Safety $e Buildings Divisio L ~ ~ Bureau of Plumbing erOy ,~:~rl~ l~y o W S . 13 F. Spruce Street Chippewa F,-kIIs, WI 54729 (715) 723-8786 PRIVATE SEWAGE SYSTEM INVESTIGATION REPORT Name of Premises T. F_ S-1- C-717 C f'~o I Y( Location Township County Master PlumberlSoil `(ester Address ' Owner r~la ~toti i~ SN I L AYAE St=~ " 'tai Address AVer' 'LE f~ S Sanitary Permit # Plan I.D. No. - Type of Inspection aft' F- Persons Present at sits /rA~: ~'t''c ED berZO <IZ, he/-'. /7,<s,, tSc~ r? •ac Type of Building: ❑ Public /idSingle Family ef4)4+p4ow BRIEF. FACTUAL COMMENT'S AND SKETCH: LC~-"~./- -n-~'~''~ .•~.~-t~? !J!v~-•G!L ,2r.-~e~. -.~'~11L?~4~'G~L~:o?~.. ~1-/11_.<~ - ~ -J~-~ . ~ • c r • I l I I l _ JT_ I%T . I t yo Vi:~ I . E t F \jATI, o IJwTra ~ D r- a M t,ca'I 'T -3 0 I ~ ~ s?,! 9 I i 1' . av _B).rl 1.0 -2 i- - J~ /3 t2 S /t M l+ +~-4 ~!L ~!!iq4.. ~.$t~L _ I ,CefkE rSa i _ - TD ` ~i .S r t T_7~~Yi ' " 4'°-t, 4'a U.C. lNt•~. '1,..!'..'' - ti. .Z - - -s~ 1, A__ Tv" ❑ SEE ATTACHED - - DISCUSSED WITH PLUMBER/CST SIGNATURE DATE OF INSPEC'T'ION -7' 25~~~ Signa e of lnspect ~ / lnapsatar Local Inspector Plumber or Rezr3onzibla Partl Wisconsin Department of Industry, INSPECTION REPORT Labor & Human Relations Safety & Buildings Division rinises Bureau of Plumbing a n rivet t y Sanitary ermtt - rP FTT umEe-r t rm ame dress ETo urnejlgan um er ress ress ' 0 C) C, v i. N! -f` l .11.2 .f _ ~~~h~,.~;J _ .usse with tgna ure )See Attached. -SBD-6197(R.11/83) Signature o is . um tng up, n- i e as a pecta is - DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING t MADISON, WI 53707 I s, r ❑CONVENTIONAL Pg"ALTERNATIVE State Plan I.D. Number: i ❑ Holding Tank E] In-Ground Pressure XM Mound t fa 556'l tf 8506335 ©-a,/ - s NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Ray Smith 1P. 0. Box 327, Clear Lake, WI 54871 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: NE SW, Section 6, T31N-R15W, Town of Forest Name of Plumber: MP/MPRSW No.: r~t. Sanitary Permit Number: Dale Hudson 6629 Croix 74960 SEPTIC TANK/HOLDING TANK: # MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.. VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: (VENT TO FRESH ALARM. FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: IPROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑NO NEAREST___~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I FNGTli 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: LENGTH. NO. OF DISTR. PIPE SPACING: COVER JINSIDE DIA.. #PITS: LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH IDISTR.PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER: ELEV. INLET ELEV. END. PIPES: FEET FROM LINE: AIR INLET: NEAREST- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE ADIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =TOPSOIL SO DDED. SEEDED: MULCHED: CENTER EDGES: [:]YES ❑NO ❑YES ❑NO ❑YES ❑NO 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. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION INFORMATION '.HOLE SIZE HOLE SPACING: DRILLED CORRECTLY: T ER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) APPLICATION FOR SANITARY PERMIT 7 wi SC .0r, 54, L H R (PLB 67) A//` ( tu COUNTY w~ oeacw~rncnr oc UNIIRM SANIjT'JARY PERMIT # InDUST~Y, LFM30P & HUMRn ArLATIO wi IV 9~ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOC ION -GFT-11" 1/4 /4 S - T.?/, N, R 1-~r It (or) TOWN OF: a e LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ?-5'6 6, 33 5 TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: X 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. ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pi ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure aultPrT' ❑ Pit Privy Existing, For Which A Previous Permit Is On File, Permit # issued An Existing System That Has Been Inspected And Is Compliant #s Fir As Soi itions. Total # Pref Site Steel Fiberglass Plastic Gallons Ta s Con ete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer. IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: R Mound ❑ In-Ground Pressure Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity /eLO0 Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch)`. REQUIRED (Square Feet): PROPOSED (Square Feet): 3 7F Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: J yc"OZ. Ica.- COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 1 2~~4_ ~ 7SQ G %d'lO ❑ Owner Given Initial 4 Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILiiR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber i K a~ r) 0 8 Sri R ore>-. 1-0 ~f ~'t I it o! r' a /00 c 1,7W -fo v (A r n W N W? C (,a IV 3 O OcD- - `<00 g r► rp cp 0 0 co N a 3 v r° Sr 11) o ~0 c ococo _ c z ' O ?cc n 0 N° O a' o c Cp vi (D O C $ ^ N a D O A a` ;r W pa OD - 0 ~ 0) cD m fDp 0 ? m v, Q 110 ~o'mw n ~m'3 ? oc 0 3 a 3 w OM 0=1 oO .<c-c00 Z =or 30 w 14 ° v - Co co z -0 D CD Q :P ,CD r- U)0 O n _ A w p C a. n 0 O a (D 7 W O ID 0 ="!R 0 CD CD co) Z ~o U) O fro p ? w ~ w= J v Z o a, m m A (YO o aCD0 3~NONa D D vOi c ° ~~ro 0 m M war: > > Qym m ~ v,~arc to F w° ac 0 f w. C m CD M 3 (Oa CD N CD r0/1 1 M FA = O IC j ..aco 3(1Qw,~j _ 0 yon-wfO D v, O c CL v O rn m win CD'`o,~w G) w w CD O y m ~ CL EL a IOD. _ tom crv-t 3=N cr (D m(2 ~rca ov C.D!R s o v o cQ c 1 c (D a CD CL csa w n c a a o cD._= o0 V a.... C :E 7 1 1 a a CD O 3 O N CD CD 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 Y/ ~ Location of Property AZ .._k SGt,) 14, Section , T 31 N - R r W Township Mailing Address 1-0 Subdivision Name AIX Lot Number A4 ` Previous Owner of Property Total Size of Parcel : Date Parcel was Created Are all corners and lot lines identifiable? ~T Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume and Page Number 42 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed. 2. Land Contract .,.3.• Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If'the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I ` (We) ee4t i. y that att e.ta temen to on this 6 o4m ahe tn.u.e to the but o6 my (oun ) knowte.dge; I (we) am (are) the owner (d) o6 the pnopeh ty ded eh i.bed in thiA ,i.n6oAmati.on 6onm, by v4ttue o6 a wwLAanty eed'nec /tded in the 066ice o6 the .County RegiAteA o6 Deedb a,6 Document No. ? o ; and that I (we) pneeentty own the ptopoded a.i to bon the eewage po-saz eystem (o& I (we) have obtained an easement,' to Auun with the above ducAi.bed pupenty, bon the conatAucti.on o6 eaid ayetem, and the same has been duty recorded in the 066.iee o6 the County Regiaten o6 Deede, ae Document No. ) . GNATURE 0 CO-OWNER (IF APPLICABLE) 6~ SIGNATURE OF OWNER DATE SIGNED DATE SIGNED H H a ST C'-105 r a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z t7 a Z H OWNER/BUYER ROUTE/BOX NUMBER 'Pe-) ~O X 3~7 Fire Number CITY/STATE ZIP Z PROPERTY LOCATION: SW Section 4/,' T__?/ N, R /.5'-w, Town of ~p ,re 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 If 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. yo E I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE C/~ 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. f ~ D I L H R Safety and Buildings Division PLAN APPROVAL Bureau of Plumbing P.O Box 7969 ❑ General Plumbing Plans Madison, WI 53707 Private Sewage Plans Telephone: (608)266-3815 Plan ldent&iiion No. 85ab3~5 µ (,alion~ Per D,iv PRIORITY PLAN REVIEW ONLY Plan Re%ie % Fee Received Petition I or Variance Fee pee S Project Name Project Location - Street No. or Legal Description County ❑ City ❑ Village Town of: The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approvalO is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of - ` plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can bew made. ~Rl ❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan 1 approval must be obtained. FOR PRIVATE SEWAGE PLANS: (1) (2 (3a (3b) (4a) (4b) (6) (7) This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only. All other system reviews must be submitted to the Bureau of Buildings and Structures. Comments: By: James Sargent Bureau Director If Questions Plans Approved By: Date Approved: Contact y cc: Private Sewage Consultant ❑ Plumbing Consultant ❑ Environmental Health County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/85) ❑ Owner ❑ Other r LU:V.1blNG VED DEPARTME7 OF INDUSIRY, LA90R AND HUMAN RE~AT40NS ~ DI ON OF SAFETY BUILDINGS SEE CORRESPONDENCEr fro v Ao $'5063 3 5 n R1 Fh` Y ~ "'fib" ~ f ~ ~ ` RECE;VED SEP 2 3 i9 b'. 3UREAU lly~ SPwt ~tiR z 3 Q'' ,R /v~ Ep W~~€+3 i~ c~)C~ M"~(~~ 1~ y Z, rig . ~YY X11 A Q T R 1 Y) lb ' Page / Of 3 Perforated Pipe Detail 0 End Vie, Perloroted End Cop PVC Pipe Nobs Located Or, 6o11om, `O~\R Are Equally Spoced R PVC Force Main w From Pump ? PVC Manifold Pipe Alternate Position Of Distribution BI N~ Pipe Force Main From Pump Last Mole Should be V> vv" y 1 n n N*ut To End Cop -End Cap LABOR P~D';HUM D~ INDto SAFELY k . 01wINGS ' r5 IDEpARTMENY ISION OF-~-- EMQ E 8506335 S~ GRRESPoND X Y `~t, " Signed:`` Hole Diameter_ Inch Lateral Inch(es) License Number: Manifold Inches Date;- Force Main " 3 Inches RECEIVED SEP 2 3 IMS PLUMRI^"' RUREAU l Straw, Marsh Hoy, Or .3 Synthetic Covering Distribution Pipe Medium Sand N ~ G Topsoil _ rsrcrex s:__ xxazsxs1J+. az F E i~ D 3 ' % S1ape Trench Of 2.'- 212 Force Main Plowed Aggregate From Pump Layer Undisturbed D Soil E 2•k Cross Section Of A Mound System Using F -75 3 Trenches For The Absorption Area G l A 3 Ft. H 1.5 B 63 Ft. Signed: •c./~. I 10 Ft. License Number: AM 4;L'<'Z9 J ~ S Ft. Date: 9 K 10 Ft. L IB3 Ft. Alternate Position of Force Main-----.-, W 4 4o Ft. L J i B K 1-3 C t4 04a Force Main From bservotion Permanent Pump Pipe Markers `NDO ' FE~~ .~Ep PRSM~; ~`d ,10N F ~ RRG SP Distribution Trench Of 2 - 2 2 1 Pipe Aggregate - 8506 3 Mound Using a Irenches For Absorption Area 'DECEIVED SEP 2 3 1986 'CUMRt~~ R(IREA(.1 PUMP CHAM16EK CK055 SECTION ARID SI'I.01 ICAI10W I VCAIT CAP y.. C. L. VLAJT YIPS ' WE:A[HFK PKOOF APF'KOVCO LOCKWIG FIjGM Uv(Jft, JUAJC Flo" BOX -MAIJHULL COVLK 25~~ WlklOOW OR F RI. SH 12'M1►J. 1 LiaN/~,-4t L ,At1Z IIJTAK€ GRADE; LB MIAI. COLIDUIT - i ItJ~ 1. r I'KUV1t)E AIK'1-1(.H-f :>EAL AI'F'NU'JkIJ JG11uT PL11NIgING ,W/C.1. PIPE tai4 I i I I ArPROVLU ,i EICTLNUII.IG 3~~~~~ I 111 I 00 CAJUIIU(t 4uTU SOLID (.1 l_ I II ALARM URI[O SOLID AP AEOR F,N7 NUM RElR10 i I C OF INDUSTRY, L UILDIN I Uti DEPARTMENT OF SAFETY AND c 93 47 ISION v SE ORRESPONDENGjmN [ ) p l: O F F COIJCK%.TL nLUCK- KISCK EXIT PERMITTED GIJL~J IF TAUK MALJUFACTURV.K IIAS `,ULH ;API'KC)VAL :;PCCIF ICATICJfas 8506335 -f TIC ANU \ TANK., MAAIUFACTUKE K: 1 R WufAbrK of UUSES: --PLK DAJ IAAJK AZE GALLOKJS DOSE VOLUME: 1 1 9 ' f,ALLU I~JS " ALARM MAAIUF'ACTUKFLk: --J1FSaK.L~z_ CAPACITIES: A=- -03WCHES OK 12-.-5) (EAU MOUCL IJUMbEK: _ Z-qc~ 0 8- ~y S IAI( HCS OR ?4 ,v_ (Ail, t;; SWITCH TYPE:(' / C° (151AICHES OR I~ > I'LIMP MANIJF A(. I OKI, W. U= Z IIJL ME:i OK ZO! UA,.i ML)OLL MUMbCK: PUMP ANU ALARM AHL I-0 HI_ SWITCH TYPE: _ En C.✓~ IMSYALLED OW SErAKAI'E CIKCUI[; PUMP DISLHAK(.E KATE GPM lM+n VEKTICAL. IaIFFcK.EAICI_ 61ZTWLLM PUMP OFF AND UISI-RIISUTIOM YINC.. FELL RECEIVED -1- MItA~JIMUM NETWOKK SUPPLY PKESSLIKE- 2.5 FEET ♦ _-_~L FEE-T OF FORCE MAIN X F T. oer.Ff(IC11o►.1 FACTOI(_FEE I- SEP 2,3 1985 TOTAL DUWAMIC HLAD = 1 L-78FLUT pLUMam,n RUREq(J IAITERNAL. DIMEWSIOIJS OF TAAJK: L LIGIUIE) DEPT H - / e Ubmersible bi ewa a Pumps MODEL 3887 SIZE WS03-WS10 RPM 1750/M IFTERS FEET IMP VARIOUS 60 16 50 lyA,w 14 12 40©eh; . yp \ 10- 30! 8 hP wst`p~, eF wso r 6 20 ` WSOSQ, 4 B f 1 ee 2 0 0 - 0 20 40 60 80 100 120 140 160 180 GPM 0 10 20 30 40 W/h CAPACITY : [CGOULDS PUMPS, INC. S84ECA FA" W NOW OWS g506335 ;RECEIVED SEP 2 3 1985 PLUMRIni BUREAU ' i r State of Wisconsin ` Department of Industry, Labor and Human Relations August 15, 1985 SAFETY & BUILDINGS DIVISION Bureau of Plumbing 201 E. Washington Avenue P.O. Box 7969 Madison, WI 53707 Wayne Severson & Raymond Smith Route 5, Box 132 U Hudson, WI 54016. Dear Messrs. Severson & Smith: Re: July 25, 1985, DILHR Field Investigation NE,SW,26,31,15W Town of Forest, St. Croix County, WI The subject investigation was conducted for the purpose of locating, if possible, a site for a new soil absorption system. Soil profiles were evaluated in eight backhoe constructed trenches. The profile description and locations are included in this letter. It was determined that two very different soil conditions occur on this property and that an abrupt boundary between the two conditions exists. The north half of the property has dense glacial till underlying about one foot of silt. This till is very impermeable and therefore the soils seasonally or periodically saturate to near the surface. 41 The southern portion of the property has a medium sand underlying the silt cap to a depth of about 54 inches where a layer of till is encountered. The till apparently decreases as one moves in a southerly direction. This area seasonally or periodically saturateswhere till is present but only to about 36 inches in the overlying sand. Therefore, this area is suitable for mound soil absorption system. Two mound sites were identified. The locations with elevations are shown on an attached sheet. One area is identified by bore holes T-1, 2 and 3. The second area by bore holes A, B and C. Representative soil profile descriptions for each area are as follows. T-1 0-4" Very dark grayish brown (1OYR 3/2) silt loam. 4-11" Dark yellowish brown (IOYR 4/4) gritty silt loam. 11-16" Pale brown (IOYR 6/3) gritty silt loam. 16-27" Strong brown (7.5YR 4/6) gritty silt loam. 27-5411 Dark brown (7.5YR 4/4) medium sand. DILHR-SED-6423 (N. 04/81) C State, Of Wisconsin ` Department of Industry, Labor and Human Relations Wayne Severson & Raymond Smith SAFETY & BUILDINGS DIVISION August 15, 1985 Page 2 54-6411 Brown (7.5YR 5/4) sand with few medium distinct strong brown (7.5YR 5/8) mottles. 6411 Reddish brown (5YR 4/3) dense sandy loam till. Estimated seasonal or periodic saturation at 54". T-2 Similar to T-1 with mottling at 42". T-3 0-511 Dark grayish brown (10YR 3/2). silt loam. 5-1011 Dark yellowish brown (10YR 4/4) gritty silt loam. 10-14" Pale brown (10YR 6/3) gritty silt loam. 14-1911 Strong brown (7,5YR 4/6) gritty silt loam. 19-3611 Dark brown (7.5YR 4/4) medium sand. 36-5311 Yellowish brown (10YR 5/6) medium sand with 112" to 1/8" dark reddish brown (5YR 3/4) dense sand bands 2" apart with common, medium distinct strong brown (7.5YR 5/8) and light brownish gray (10YR 6/2) mottles. Estimated seasonal or periodic saturation at 36". T-A, B and C These three profiles are almost identical to T-2 with seasonal or periodic saturation from 36-42". Sincerely, Edmund M. Drozd, CPSS Soil Scientist Section of Private Sewage (608) 267-9803 EMD:1529v Enc. cc: Leroy Jansky, Private Sewage Consultant - District 6, Chippewa Falls Harold C. Barber, Zoning Administrator - St. Croix County Representative Paulson DILHR-SBO-6423 (N. 04/81) _._....._:M...,gym..„_y.~....„_,.T..__..-., L IMLHR Safety and Buildings Division PLAN APPROVAL Bureau of Plumbing P.O Box 7969 ❑ General Plumbing Plans Madison, WI 53707 Private Sewage Plans Telephone: (608)266-3815 r 9 - „ Plan Identification No. p Claiions Per Da 's el, CD PRIORITY PLAN REVIEW ONLY - 1 Plan Review feE~ Received Petition For Variance f ee Rec. Project Name Project Location - Street No. or Legal Description my ❑ City ❑ Village Town of: - ,may The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan approval must be obtained. i FOR PRIVATE SEWAGE PLANS: (1) (2 (3a) (3b) (4a) (4b) (6) (7) This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only. All other system reviews must be ! submitted to the Bureau of Buildings and Structures. Comments: By. I James Sargent 74,z, Bureau Director If Questions Plans Approved By: i Date Approved: Contact ♦ X ' cc: Private Sewage Consultant ❑ Plumbing Consultant ❑ Environmental Health County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/85) ❑ Owner ❑ Other SBD 66.7_8 (R. 08/83) (Plb 100a) (WisStats. S. 145.02) STATE OF WISCONSIN DILHR Detach And Return Upper DIVISION OF SAFETY & BUILDINGS BUREAU OF PLUMBING Portion Of This Form With 201 E. WASHINGTON AVE. RM 141 Any Return Corresponden,a f P.O. BOX 7969 i~ MADISON, W153707 ti 608-266-3815 DATE: 09/23/85 PROJECT: Z ~9 Stith, Ray - Residence 3d(b) NE,SW,€,31,156- Tn Forest Boldt`s Plumbing t St. Croix W1 820 lain` Street Baldwin, WI 54002 PLAN ID. # €35-06335 DETACH HERE PROJECT NAME Smith, Ray - Resi Hence PLAN ID. # 85-06335 This is to acknowledge receipt of your plans and specifications for the above-indicated project. Preliminary review indicates the required fee is • Fee Received is $ 80.00 Plan accepted for review. ❑ Underpayment Please submit additional fee. Plans will be held in abeyance. ❑ Plans being returned. ❑ Overpayment-Refund forthcoming. ❑ Additional-information required. SEE BELOW. ❑ No fee has been remitted. Plans will beheld in abeyance. 1. Plan Submission ❑ Soil boring and percolationtestdata on 115 completed Additional information shall be submitted in_duplicate unless byCmVfied Soil Tester. (11 copy) specifically noted. ❑ Petition; For Modification signed by county, owner and Plans not clear, legible or permanent. notarized. (1 copy) ❑ All information submitted-shall be signed, dated and sealed or ❑ Complete data relative to anticipated use of building. stamped in accord with Section 1LHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required. (1 copy) Administrative Code. ❑ Affidavit enclosed. ❑ Condomjnium declaration. (1 copy) ❑ Plot plan showing location of land parcel (distance from nearest road intersection, etc.), lot size and all distances from IV. Hokfing Tanks private sewage system to buildings, lot lines, well, water ❑ Holding tank profile showing vent, manhole, alarm, course; swimming pools', water service piping, all weather ser- and.manufacturer if state approved. Complete vice road, etc. Show benchmark with permanent elevation: construction details if site constructed. ❑ Holding4ank agreement signed by owner and local 11. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed). ❑ Application for use of an Alternative System signed by owner ❑ Reason for installing holding tank. Statement from and notarized. (1 copy) county or soil boring andpercolation test data on ❑ County onsite required. (11 copy) ❑ Design calculations. 115 completed by CST, showing that a soil absorption system Soil boring and percolation test data on 115 completed by cannot be installed on the land parcel. Certified Soil Tester. (I copy) ❑ Affidavit for all-weather service road (enclosed). ❑ Cross section of system. ❑ Pipe lateral layout. ❑ Plan view of system. V. Dosing Information Verification fo Exception Status Formby county. (1 copy) ❑ : Calculations for total dynamic head and gallons pumped per cycle. III. Private Sewage Systems ❑ Size, length and depth of force main. Ground slope with 2' contours in entire area of soil absorption ❑ Detail and model of pump or automatic siphon, including system extending 25' minimum on all sides_ size, pump curves, drawdown, and average flow rate (GPM). •Location of area suitable for replacement system- provide soil ❑ Cross section of dosing tank showing pump(s) or siphon(s). data. Construction details of septic, holding or dose tank if site VI. Systems in Fill (Fill must be placed prior to plan submission.) constructed, or tank manufacturer it state approved. ❑ Total area filled (fill to extend 20' beyond edge Construction details and cross section -of soil absorption of trench before side slopes begin.) system. ❑ Depth and type of fill. Copy of signed onsite report by county or district staff. ST. CROIX COUNTY WISCONSIN ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 August 28, 1985 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Raymond Smith property located in the NE14 of the SWk of Section 6, T31N-R15W, Town of Forest, St. Croix County, revealed suitable soils at a depth of 36 inches, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincerely, Thomas C. Nelson Assistant Zoning Administrator 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 NE SW 34 S 6 T 31 N/R 15 E(or)W Forest St. Croix Street Address: Subdivision: County: Landowners Name: Mailing Address: Raymond Smith 117 5th Avenue, Clear Lake, WI 54005 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: w J WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY b BUILDINGS, BUREAU OF PLUMBING P.O. BOX 79699 MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St. Croix Location NE 1/4, Sw 1/4, Sec. 6 T 31 N. R 15 VOW W Town0 Forest Street Address Lot No. Block Subdivision Landowner's Name: Raymond Smith 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: ~..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 n-um-5ersissueU-Fo you.) (XIone of the applications needing a quota number. The quota number assigned to this application is 59 - 17 - 6 . ❑ for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. 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. [J for an application on file prior to February 1, 1980. LIfor 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: ❑ a failing conventional soil absorption system. 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 I certify that the above information is true and accurate to the best of my knowledge. Name Thomas C. Nelson Si re County Official) Title Assistant Zoning Administrnt-,,,. Date August 28, 198 DILHR-SBD-6158 (R 12/82)