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O Cr D d Er' M' 6 p (D D1 CD < 'CD o- f ~ faD O d O 7 0 .n•. ,n., O CD 0) Er 5- CD CL o FA, :3 j 3 3 N~.O O l1 O v 0 O O 0 x iy O CD 'D O X O Vi A O CD j 00 b v aro o + O O o c~D ° o N ° N ° OL a, as N Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP _Z2La~y1137 orfal SEC. T N-R 17 W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 1jHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYST e Cn, . Q3 C Wei C3, /o• ~Clrl~ • as e- Nr~ , eo' 5z 51 ✓d f 12' INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used q Elevation of vertical reference point: zoo,0 r Proposed slcY site: ~ pe a at t si: 2--f7, a f' SEPTIC TANK: Manufacturer: _ Liquid Capacity: /QUA e? Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: n ~ Tank Outlet Elevation: 97- 9~ f Number of feet from nearest Road: Front, Side,O Rear, O feet From nearest property line Front,0 Side,0 Rear, O feet Number of feet from: well /30 , building: /0 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE } PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Sip on Manufactur Pump Size Elevation of inlet: Bottom of n elevation: Pump off switch elevation: Ga o s per cycle: Alarm Manufacturer: A rm itch Type: Number of feet from nearest property lin 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: l L°S Trench: Width: Lenth: 52 Number of Lines: ,G Area Built: Fill depth to top of pipe: Number of,feet from nearest property line: Front, Side, © Rear,O Pt./Q'~ Number of feet from well: i Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pit D t r: Liquid depth: Botto of seep ev tion: Area Built: Has either a drop box O or distri utio bo O be used n any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: lev on of Otto tank: Elevation of inlet: Number of feet from nearest prope y line: r n , Side, O Rear, 0Ft. Number of feet from el Number of feet f m buil g: Number of feet from nearest road: Alarm Manufacturer: p Inspector: Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS INSPECTION REPORT FOR SAFETY & BUILDINGS P.O.BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigne<,I NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER IECTI N D E: John Dalton R. R. 1, Hammon d, WI 54015 07 BENCH MARK (Pe m ranent reference point) DESCRIBE IF DIFFERENT FROM PLAN: r . PT. E V.: J CST REF. PT. ELEV.: SE SE, Section 4, T29N-R17W, Town of Hammond B Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Dale E. Hudson 6629 St. Croix 74955 4 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER ~i f PROVIDED: PROVIDED: BEDDING 0 Z/ YES ONO DYES ONO : VENT DIA.: VENT MATL: HIGH WATE I ALARM: NUMBER OF ROAD: PROPERT WELL BUILDING: VENT TO FR ESH YES ❑ NO D FEET FROM ¢D~`/ LI~~ YL IONO NDOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER OYES ONO PROVIDED PROVIDED: GALLONS PER CYCLE: PuMPANDCONTROLSOPERATIONAL DYES ONO DYES ONO (DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL BUILDING VENT FRESH PUMP ON AND OFF) FEET FROM LINE' AIR INLET DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH - DIAMETER MATERIAL AND MARKwG 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 LENGTH NO. OF DISTR. PIPE SPACING COVER f TR ENCH ES. INSIDE CIA #pITS. LIQUID DIMENSIONS r nMrgbRIAL` PIT DEPTH: vh'UEYIH FILL DEPTH DISTR. PIPE DISTR. PI DISTR. PIPE MATERIAL: N S R. BELOW PIPES / f ABOVE OVER EL V. INLET. ELEa.EN NUMBER OF LRN PER Y WELL: BUILDING: VENT TO FRESH PI FEET FROM - V AIR INLET: p r NEAREST--~ MOUND SYSTEM: d f 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 O NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS. OBSERVATION WELLS: DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DYES ONO DYES ONO CENTER. EDGES. DEPTH OF TOPSOIL. SODDED: SEEDED: MULCHED: OYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERALSPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: ELEVATION AND PIPES DIA: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DR I L LE D CORR ECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO DYES NO COMMENTS: PERMANENT'MAR KERS: OBSERVATION WELLS: LNNUrBER OF PROPERTY WELL: BUILDING: DYES ONO D YES ONO NEARESTO - LINE: Gta ~ ~ D Sketch System on Reverse Side. Retain in county file for audit. [SIGNAT E: TITLE: DILHR SBD 6710 (R. 01/82) 'cons' APPLICATION FOR SANITARY PERMIT ILHR COUNTY (PLB 67) +ON0000100• OEPRRTmEMOF UNIFOFtp SANITARY PERMIT # ~O WtDUSTRY, LRQA 6 Human REt.RTK*-M i~Y'/ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPTER"YOW NE R MAILING ADDRESS ~ l" I9 " inn PROPERTY LOCATION , 1/4 ,61/4, S 174 , T N R / 8 (or) TOWN OFD ~~/I/ lnJj(l LOT NUMBER BLOCK NUMBER SLIANVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER N AL TYPE OF BUILDING OR USE SERVED 0O d 1 or 2 Family Number of Bedrooms. 3 Public (Specify): /1' THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair LJ Replacement Soil Absorption System ❑ Revision ❑ Privy Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy Existing, For Which A Previous Permit Is On File, Permit # issued An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total' #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity V Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound In-Ground Pressure Total of efab. a Steel Fiberglass Plastic Gallons Tanks . oncrete s ucted Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer. - PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): '/off. --a. tT ❑ Private ILl 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: 9 . rp ✓ s' as~-c_ f P ~ - Gam" (7/~ ► Y-41 -:5 Plumber's Address: Name of Designer: C r r 1&Z 0 COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: i El Disapproved /5 L m•-)S ❑ Owner Given Initial / Approved Adverse Determination Re son for Disapproval: Alternate course(s) of Action Available: D14HR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber OpAqv-e, / ;Vjt, /1?M C7 ;qp o c <q - at ~...1J 'S"r All x t 'C~!Ct, ~ r' ~ rc~ ~ ~ /lam; r /1~.: t: r'~,i~l~, Cl 9,?, y3 /f~t~/irk J r':lr"L" fl~tPrt; 85- 9943 o Re 33 u. Fro x i ( " W. I ml 94 ,yea." ~ S SePt.' ro^~ jet i /3 F yi ~~,2 /a(Al ad' 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 r / ; Location of Property S"Z- ~C'✓ Section T x N _ R /7 W Township G)~J?l~l1 Mailing Address 71 Subdivision Name ,J Lot Number Previous Owner of Property _ /~,~p Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume -:74r,- and Page Number 2~3 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. PROPERTV OWNER CERTIFICATION I (We) ceAti j y that at t 6 tatementA on .th,i.6 6oAm ace tAue to the beet o6 my (ou 1 hnowtedge; that 1 (we) am (ane) the owneAl6) o6 the pnopehty deecAi.bed in thiA in6onmate,on 6onm, by vi tue o6 a wat.anty deed aeeonded in the 066ice o6 the County RegiAteA o6 Deedb ae Document No, and that I (we) pneaentty own the pnopoaed bite Got the 6ewage diApo4at 4yatem (on 1 (we) have obtained an eaeement, to hun with the above de c i.bed paopehty, bon the con4t4uctron o6 da.i-d 4ybtem, and the dame hab been duty n.econded in the 066ice o6 the County Reg.i.aten. o6 Deed6, a6 Document No. j , JIGNATURE OF OWNER SIGN TURE CO-OWNER (IF APPLICABLE) 3 S DATE SIGNED DATE S GNED r, z ' y a ' ST C'-105 r" r a SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County z _ d OWNER/BUYER t/0A17 P a/~~/f ~ ROUTE/BOX NUMBER, Fire Number CITY/STATEZIP PROPERTY LOCATION: 1& 14, Section T Town of 17P /nQy761 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. 0 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v 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 t DATE ~2 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. i 4b e Z ` o;.;:. 0 FV<. e U ai = a v v - ....rf o c. O O V L: p 0 °f0 C p •C M L. O 0-- C p) & V m y t ''C cc C>1 •i 0 H~ W o ~v c (D ca c c~`c c73~ C'3 03000.0 ;Ea c a G~«O. = V Ay 0 0`C ~ C N co t7 O W ►►r-.S~~ma w~°c' 8\ 4 U) .!2 E O 0 3 0 3 V M co CM -0 CC w Q Q cNv`~ wo` Q'I- cm 3 vtmm~E 010 CC C 0) CC y Z co Co a 4) 0 ca -coa.C t ovio 3 0 .0 (D iii 3 O'a 0 a.. E! td C , •0 co - a cti 0 o Z M.9 et O Q O O (f 0 (D 0 C7 O N u Q a Q 0 GO O 0~O C ti C y 0 0 0 D O C fn cT R1 r.; V1 r w 0 p 3 C .o Z CC Rf N C 0 E O rnZ •C _ > 7 7 w E O C C r O o 0 O cQ O t C C C N N N co <o'- m e Nw O V p~+00 C D 03 0 N"0 O. 0 N C C' c o CM CM _ o o 13 h Y cu co 0) - >,"L t 00 a p D i M Z O OE p p C p V V c>L Y O E = c c 0 `o rN• N M V1 wcc•, H e c N 'J 0 MPA TtIIIENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDU§TRY, DIVISION ' L P.O. BOX 7969 RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 LABOR HUMAN AND (H63.090) & Chapter 145.045) OCAT :5 , f/ SECTION: OWNSHI OT NO.: BLNO. : SUBDIVISION „NAME: ~4l4 / T N/pa a! /71 (or T X66 x j,//J COUNTY: OWN `S BUYER'S AM : MAILING ADDRESS: DATES OBS RVATIONS MADE USE ,,-t~xx BEDRMS.: COMM R A SCRIPTION: PROFILED S P IONS: PE OLATION TESTS: I Residence 41, JWNew ❑Replace 9_ 170 - RATING: S-- Site suitable for system U= Site unsuitable for system ONVENTI NAL: MOUND: IN-GROUND-PRESSURE : SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) MS EA CIS ®U EIS CCU CIS ®U❑S DU DESIGN RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: Ff PROFILE DESCRIPTIONS BORING TOTAL DEPT H T ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER EPTH;W. ELEVATION OBSERVED ES . IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ' ~ ~ • /7 ~ /y,, Is ' . ,?D" ~S ,lv O~~ n/n o ,/l~" B- 3 x 7, 99'51 9,? ,413' f I • z' ' f n " - Z W 12 n Mf ; ° r f r l~ B- 161-12' B- C~•~ • 99,93 ' P >~j 12 l u iL ".8/7 In s B- ~t PERCOLATION TESTS DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IA16HES AFTERSWELLING INTERVAL-MIN. PE tOD t P Rl D PER OD 3 PER INCH P_ I o P- P- P_. PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEV TION 9l° f ~ I E , I 1~ i r ? i p I - ' l . f r 1 s t T t ( t t t I, the undersigned, 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 the location of the tests are correct to the best of my knowledge and belief. NAM '(print): TESTS WERE COMPLETED ON: A_'~)4 I✓'«-moo ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNATURE: u-_ DISTRIBUTION: Original and one corny to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER tf l4 / r m y 5f i p of s 6 CGVe r .34 , 17 !4 /L IfI JF/M.~ ~ ~ if0 •'T Z. ~ f} d ~ ~ Q. r. r ~.,-'t r RIM o O F B3 - 99 -8 C, :De 85 r 7 r «1z p a Sep j.t,"u ~x ! :y / / e O t~/f ~r'rl p • I a., J a' z C3" II 3 s 135 /area h~ pa6 2