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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
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OWNER ~gV1A 'S Lb"~V_64& "-A>d TOWNSHIP SEC. _ T N-R r-j W
ADDRESS ST. CROIX COUNTY, WISCONSIN ' g 3y
AW, :s5457-
SUBDIVISION VWV;f LOT LOT SIZE 3 Z
PLAN VIEW
Distances and dimensions to meet requirements of I1I-1R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
b~
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ffr 1
r
iy
INDICATE NORTH ARROW
h
BENCHMARK: Describe the vertical reference point used (it 6:F l` + { •~'x_
Elevation of vertical reference point: /Mw Proposed slope at site: 4 Yel
SEPTIC TANK: Manufacturer: Liquid Capacity: 12 5C
Number of rings used: Tank manhole cover elevation: qq.
Tank Inlet Elevation: Tank Outlet Elevation: q,5.
Number of feet from nearest Road:
Front,O Side,O Rear, feet
.From nearest property line Front, 0Side, 0Rear, ~ OV' j lG'C feet
Number of feet from: well ,?V, /L:1building: 5L)
(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/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, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: 6 4z Trench
Width: tA -,e, Len$th: Number of Lines: 3 Area Built:,57-6
~
Fill depth to top of pipe: Z1-6
Number of feet from nearest property line: Front, Side, O Rear, O Ft.
Number of feet from well: UrIG Ice
Number of feet from building: 45-6"
(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 'ob:
License Number: /,I/
J3/84: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
EXCONVENTIONAL ❑~ALTERNATIVE Slate Plan 10 Number
• III asvgnetll
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE
James .Bankston 1630 Camelot Ln., NE, Fridley, MN 5432 42_2
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN Fox Valley Sub. REF. IT. ELEV.: CST REF. PT. ELEV
SE-',, of the SEA-, Sec.23, T29N-R19W, Town of Hudson, Lot#6
N~rne of Plumber. IMPIMPHSW I G,unty Sant arv Fermi; Number.
Paul R. Cudd 2739 St. Croix 69676
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INL E T FLFV TANK OUTLET ELEV WARNING LABEL LOCKING COVER
! PROVIDED'. PROVIDED.
aeoolNG vENTDIA vENrMArI 11-111,11VIAIEV+ / _ ❑YES LINO ❑YES LINO
NUMBER OF ROAD PROPFRIY WELL BUILDING ~AENT TO FRESH
( ALARM FEET FROM LINE 'R INLET
❑YES L`, NO ❑YES LINO NEAREST
USING CHAMBER:
lR^.:NUFACTUHEI? BEDDING LIQUID CAPACITY PUMP MUDFI PUI.1P SIPI It)N VANUr IIIItFH WARNING LABEL LOCKING COVER
PROVIDED PROVIDED
❑YES LINO ❑YES NO DYES ❑NO
GALLONS `ER, (,,'CLE: PUMPAND CONTROLS OPERATIONAL NUMBER OF PEt')PFHTY wFLL BUILDING, VENT TO FRESH
(DIFFERENt,E BETWEEN FEET FROM NF AIR INLET
PUMP ON AND OFF) ❑YES _ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing A"nF T, I+ aAT111 AL AND FIAHKIN
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:
BEDITRENCH- WIDTH LENGTH Nn I)F DISTR PIPE A(INr, NSIDEDIA FPiIS LIQUID
BENCHES nTEI+IAI PIT DEPTH
DIMENSIONS _
GRAVELDEPTH FILL DEPTH (11" PIP, DIS1H PIPE DISTR-PIPE MATERIAL NO DISTR NU ER OF PROPERTY WELL BUILDING VENT TO FRESH
IRI L[)w PIPIS ABOVE COVER FE EV IN,I I ELEV END 1 PIPf",S FEET FROM LINE, AIRfINLET
I NEAREST -s
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-
❑ meets the criteria for medium sand. TIONS MEASURED.
YES_ LI NO
SOIL COVER TExTUR JPI Hn1ANF N T 41ANh F H S OBSERVATION 11,1 LIS
❑YES LINO _DYES NO
DEPTH OVER TRENCH BED DEPTH DVFR TRENCH BFI) DCPiH()F TOPS()IL SODDL I) 11F FUFU IMULCE11D
CENTER EDGES
I 11 ES L ,I NO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO-OF LA TF HAL. SPACING GRAVE L DEPTH
HE LL)6N PIPE F I I L D F P TII ABOVE COVE R
NCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR PIPE JMANIFOLD MATERIAL 17 DISTR DISTR. PIPE UISTHIRU!ION PIPE MATERIAL & MARKING
ELEVATION AND ELEV. ELEV. DIA. ELEV. PIPES DIA
I
y DISTRIBUTION _
INFORMATIONS HOLE SIZE HOLE SPACING; DHIL LE I) COHHFCI L Y CO VFR MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLAlIS
❑YES LINO ❑YES LINO
COMMENTS: PERMANENT MARKERS. JOBSERVATION WELLS. IFEE ROF PROPERTY WELL: BUILDING.
FEET FROM LINE.
EYES 11 NO YES ❑ NO 1NEAREST--~►
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Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE
DILHR SBD 6710 (R. 01/82)
wlsconsln APPLICATION FOR SANITARY PERMIT
IZI DILHR ~t• 'r' O'X COUNTY
~ M OEPROTMEnT OF (PLB 67) UNIFORM SANITARY PERMIT #
InOU, TRY, LRSOR 6 HUMFIn RELRTIOnS (p
lV V
-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 rever~re side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
James Bankston 1630 Camelot Ln., Fridley, 55432
PROPERTY LOCATION
~;W o Hudson
-5 C 1/4S~ 1/4, Sze , T 2 9N, Rj
-9 WN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
6 . ox V a l.Ley .'ill uradley Drive ,ast
TYPE OF BUILDING OR USE SERVED Llp~. W. Qaa - 7/5 -
L~ 1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
IX 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 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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity 1350 1
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: f1@ er ~oncrete Products
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
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):
'Class 1 ''20 828
® 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): Si tur 1 MP/MPRSW No.: Phone Number:
Paul R . Cu .d r J iP ASIi 2739 (?15)425-2049
Plumber's Address: Name of Designer:
5, Boa. 364, fiver _Fails, 54,)22 ;)avid B. Fogerty (3233)
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
? + 1 g~ ❑ Owner Given Initial
f C/~~ Jt~- O Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 .
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.) ;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
Forill
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L a : a c t y a;a to o f P r o p e r t y e C is i. o 11 T N ft-Z~lW
lownelai j
Mailing Ad d x r e a~ W~ ro~__ 1_..~-•
Sufadiviiiion Nauie_ -
Last NuruLer
PraaviCiu.a Owner of Property
:l'otaal Size of Parcel.
Dare Parcel Was Created
Are all corners idlentifiaable? Yes No
Include witka a:Fcis aapllic ct ion one of thu tollowitiv;
. Cerrified Survey Map
i, ,a d
.1-and Contract, aJr
1)4:,cuutent wtaich descril)es they property
11;:,,Of'EHTY 0wj%, R CERTIFICATION
10.14a)) certify that a!i statements ors this form dr'e true to the test of my (our)
",nk'jw1adpe; that I (we) aam (,are) tho shiner(s) of the property desr,sitied in this
afrarrnation for;'n, by vartua► of as wair-raanty deed recorded in the Office of the
alasnty ReU111 r of Oaaads as Document hlaa. ~Z! f_ _ ;Barad that I (we)
, ' - rniy own the propoiwd site for the sewage disposal system (or I (we) have
W:_wined an 4:aaser,,jeajt, to run with the tatwve desCribod property, for the
construc,z l of uid system, and the erne has fleets duly recorded in the Officu
ut 6-10 °I. "ty f1 , Of of Deddi,, Wi Glocumenr
S, (aNATURa: Of oWN6R
SIGNATURE OF -OWNER alf AP l_ICAeI_t)
DATE O fIATE
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
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OWNER/BUY ER.,~~~ ~~r?~`llE~fl 1~=Yi~
ROUTE/BOX NUMBERS Fire Number
CITY/STATE ~~~y }g~_ ,fCF~' ZIP S "-_y ,
PROPERTY LOCATION:, Sections T _N, R_ W,
Town ofd St. Croix County,
Subdivision`` y~ Lot number K
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 stems 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
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 Zoni g Office within 30 days
of the three year expiration date.
SIGNED t~
DATE 11 f
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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, cc DIVISION BOX HLABOR AND
RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: j SECTION: OWNSHIP/MU-l4W4PA-E+T-Y: LOT NO.:BLK. NO. SUBDIVISION NAME:
_ 4 /T 2zN/RZ E (r
COUNTY: OWNER'S/&UY-F. A}AME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence K,New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: tN-GROUND PRESSURE: ISYSTEIVI-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑S ❑U EIS [:]U ❑S ❑U EIS [:]U EIS ❑U -
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AN DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- r 77~ ~C C r f 1. . 7+ n
11,7 a,
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B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD( PERIOD2 PERIOD3 PERINCH
P- 3 i S 3 e S
)1
P-
P- 7' 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
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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.
NAME (print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
71,
n CST SIGNATURE_._
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILLIR-SBD-6395 (R. 02/82) - OVER
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CORP LET Ed W 1150a IN 300 -0,
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c- one E-l:am nation oversight., constrUCtlOn, or any damace that may result in or
auon.
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