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Form - S T C - 104
' AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. :'t/ T N-R / W
I
, J'ri ~l L I r
ADDRESSt ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i a~
i
9:3.
7 11,3
`r. l e t vi cs = =
1
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ~f~ 1.~ /`i_
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: ;1 Liquid Capacity: _c
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, 0 Rear; O~ feet
.From nearest property line Front,OSide, 0Rear ,0 feet
Number of feet from: well ~LL building: 13 -
(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, 0 Ft,
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Z,:~)G Number of Lines:
Area Built: ZOO()
Fill depth to top of pipe:
T
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).
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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated:
y v ~~P Plumber on jo
License Number: 3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOl HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.7. BOX 7969 BUREAU OF PLUMBING
i.iNDISON, WI 53707
El CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
El Holding Tank El In-Ground Pressure El Mound (If assigned)
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
E4)V 6 5 4 /7r X, / ~e dP,~~v.//z it S3 Vva 3
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. j1 REF. PT. ELEV.. CST REF. PT. ELEV..
Name of Plumber. MP/MPRSW No.. lCommy Sanitary Permit Number:
SEPTIC TANK/HOLDING TANK: 00
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
~t PROVIDED PROVIDED
"V e /~0` YES ENO DYES ENO
BEDDING: VENT DIA.. VENT MATL. HIGH WATER MBER ROAD: JPROPERTY WELL: JBUILDING: VENT TO FRESH
NU OF
ALARM E LAIR INLET
FEET FROM yC LIN
XYES ❑ NO ❑ YES ❑ NO NEAREST ~D O y(p ~D I , Q
DOSING CHAMBER:
MANUFACTURER. 71NG J I L IQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURERWARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES ENO DYES ONO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PR OPE RTV JWELL IBUILDING.I (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ILE N(,TH 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 LENGTH NO OF DISTR Pj PE SPACING COVER JINSIDE DIA 3 PITS LIQUID
D TR ENC NQS / "1 ~j~ PIT DEPTH
DIMENSIONS
~
GRAVEL DEPTH FILL DEPTH U P1 DP1g E DISTR. PIPE MATERIALNO DISTRNUMBER OF ROPERTY WELL BUILDINGVFRESH
BFLOwPIPESABOVE ovEHE FEET FROM
PIP LINE ET
~r
V ~ NEAREST
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-
D YES NO meets the criteria for medium sand. TIONS MEASURED.
E
SOIL COVER TEXTURE PERMANENT MARKERS JOBS111VATION WELLS
DYES ENO EYES ENO
DEPTH OVER TRENCHBED JDEPTH OVER TRENCH BPD DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
DYES ENO EYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACING. J GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA. ELEV.. PIPES. CIA
ELEVATION AND .
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
DYES ENO DYES ENO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SI ARE-~ ` „I~ "A~TITIEE
DILHR SBD 6710 (R. 01/82)
DEPARTMENT OF INDUSTRY iNSPECTiON REPORT FOR
i._ABOR & HUMAN RELATIONS SAFETY & BUILDINGS
=.o. Box 7969 PRIVATE SEWAGE SYSTEMS DIVISION
,MADIS()N, WI 5,3707 BUREAU OF PLUMBING
Y&ONVENTIONAL ❑ALTERNATIVE State Plan I.D. Numbe,
❑ Holding Tank ❑ In-Ground Pressure "a '9"ed'
❑ Mound
NAME OF PERMIT HOLDER. I
JADDRESS OF PERMIT HOLDER:
Dennis Elrod INSP crloN ogrE
R. R. 1, Beldenville, WI 54003 _ rl 1~~
BENCH MARK (Permanent reference poi t CRIBE IF ✓ „y
" I DIFFERENT FROM PLAN
DES . OST REF PT ELEV I
NW4 SW4, Section 34, T29N-R19W, Lot#8, Stewart's Addn., Town of Hudso REF. PT ELEV
Name of Plu mbe~
MP/MPRSW No. County.
Paul R. Cudd san,ta,y per-,t Number:
2739 St. Croix 64914
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
/ y LIQUID A CIT ' TAN INLET ELEV.. TANK OUTLET ELEV.. WAOVRNIING LABEL
DED . LOCKING COVE?
PR
PROVIDED.
BEDDING: VENTDIA VENT MATL HIGH WA ER (9 v r RYES LINO EYES LINO
ALARM. NUMBER OF ROAD: Lq ppE WELL BUILDIyG: VENTTOFRESHJ
YES LINO FEET FROM AIRA-1.
I
❑YES LINO NEAREST
DOSING CHAMBER: !S o
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL
PUMP!SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
❑YES LINO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ❑YES LINO ❑YES LINO
(DIFFERENCE BETWEEN NUMBER OF PROPERTY weu BUILDING AVENT IR INLET FRESH
PUMP ON AND OFF) FEET FROM LINE I AR NLET
SOIL ABSORPTION SYSTEM. Check the soil moisture at the❑depth of plowing NO - NEAREST
[ N(,TH M
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE DIAMETER ArFH'`'' AND
,aHKltir,
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM-
BED/TRENCH WIDTH _ E No of
DISTR. PIpE S~ACINC, COVE INSIDE Dln LID
ReNC'"y~ /V/ =Plrs LEE
DIMENSIONS wI jIl D T PIT
/ P ~ DEPTH
GRAVEL DEPTH FILL DEPTH D . P P
BELOW PIP FS ABOVFVER E ~I ~ E PI ~ DISTR. PI E MATERIAL. NO DISTH R OF WELL. UILDING. VENT TO `r RESN
(`/YA SSSJ!! PIPES NUMBE PROPER TV
FEET FROM 'LINE.
NEAREST--s ~c~••
MOUND SYSTEM:
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES LINO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER rexruRE
PERMAN ENT MARKERS OBSERVATION WELLS
DEPTH OVER TRENCH BED DEPTH OVER TRENCHBED ❑YES LINO ❑YES ❑NQ
CENTER EDGES DEPTH OF TOPSOIL SODDED SEEDED _JI
MULCHED
❑YES LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
DIMENSIONS TRENCHES FILL DEPTH ABOVE COVER
MANIFOLD PUMP I
MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEVATION AND ELEV ELEV DIA ELEV. PIPES
DIA.
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY
COVER MgTEHIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: PERMANENT MARKERS 0 YES ❑ NO El YES ❑ No
JOBSERVATION WELLS NUMBER OF PR oPERTV WELL BUILDING
LINE'
❑YES ❑Np FEET FROM
❑YES LINONEAREST -
Sketch System on
Reverse Side. Retain in county file for audit.
SIGNATURE:
TITLE. -
DILHR SBD 6710 (R. 01/82)
Wisconsin ' APPLICATION FOR SANITARY PERMIT
93ILHR (PLB 67) St . Croix COUNTY
111111 DERRRTMEnTOF UNIF RM SANITARY PERMIT #
InOUSTRV,LRBOR&HUMRn RELRTIOns
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
Dennis Elrod Rt. 1, Beldenville, WI 54003
PROPERTY LOCATION XXXX_
Nu'J 1/4 SVJ 1/4, s 34 T29, N, R 19 \XDaXMx: Hudson
, *10 W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
8 Stewarts Addn. N Gilbert Road
TYPE OF BUILDING OR USE SERVED /_0 ~aa //4%I- !O (JOd
1 orxFamily Number of Bedrooms. 4 Public (Specify):
THIS PERMIT IS FOR A:
21 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 X 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 1200 1 X
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: Wieser Concrete 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 2 1000 1000 Cpl 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): Irature: P/MPRSW No.: Phone Number:
Paul R. Cudd MPRSW2739 (715 425-204
Plumber's Address: Na e of Designer:
Rt. 5, Box 364, Ri.v r Falls, WI 54022 Arthur Wegerer
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
~ ❑ Disapproved
j ❑ Owner Given Initial
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.
APPLICATION FOR SANITARY PERMIT
S T C - 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/contractpj:,("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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
p,
Owner of Property + I o i j } l i l t 5 1 )
Location of Property 5 ' Section T N - R~ W
Township
Mailing Address
Subdivision Name J } wa r t, )~~`1 I~~ C!Cl
Lot Number
Previous Owner of Property= j !C
t
Total Size of Parcel ~2~^
Date Parcel was Created 12
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 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 dehiys
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) eeAti.6 y that a U statements on this 6onm ahe .tAue
k.nowtedge; that I (we) am (ahe) the owneA(s) o~ the pAopenty dani.bed in this
in. onmati.on 4ohm, by vi tue o6 a wa4Aanty deed neeonded in the 066ice o6 the
County RegisteA o6 Deeds as Document No. ; and that I (we)
pees entt y own the pno pos ed site j on the sewage pos system (oA 1 (we) have
obtained an easement, to nun with the above descAibed pnopeAty, ion the
eonsthueti.on o4 said system, and the same has been duty neeonded in the 046i.ce
o e~County Regi.6teA ob Deeds, as Document No. ) .
SIGNAT RE OF, WNER SIG ATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
1 -
LOCATED IN THE NW 114. OF_THE. SW 1l4 OF SECTION 34',T2 N1
R19W,-TOWN OF HUDSON ; ST.. CROIX COUNTY. WISCONSIN.
yy - r.
rEST Il4 tGRwER - - - - _
I `
ECTION S•
6 i TZ1N,R!e♦ NCR'N LINE OF SW I/4
Q E - / UNw,ATTEO - L4NCS• AE CoRNE.A CI
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Kw U4 OF Sw iA~
I y: S 0 0 o
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t ; P• r'_ y \ 8 r Re000 - ! iIG. Of I A110uwD TO eE AUTO- n
t ~ o_ ~rATICALLT vACIIED ti►OM
0 0- - c n o4 s 2 22 ACRES A l t•16 N_ NN i N
STREET CitCNS10N
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Sal. Ryt9 54'40-C
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z z 45 ACRES
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- n . _ _
LEGEND
0 'A " y _ •v _ Orw. 6O COUNTY SECTION CORNER wCNUrENT FOUND•eERYTSCN CAI.--
' - , 4 0 6nlR 2 w • 1 IPOR PIPE WEIGHING 1 6e0/LINEAL Ft. FOUND
ti 0- 2'X SO IRON PIPE WEIGHING S E54y/LINEAL FT. SET
3
- P~ \ + 4 •\1~ - - ALL OTNEP LOT tURNERS STA[EO WITH {`[24- 1110% P,tE
' .i_ T _ « .:\e: WE IGNINO 1.48••/LINEAL FT.
/r 4 - + \ IA w ~N h A • 1 A 24 IRON PIPE ItE IGOUNG 16[41/LINEAL FT SET ON LINE
s..- -tee.'- G4• h _ , p rr_
_~~{.Ay t/• t' • NW -$w A FENCE r
A 41 p
TRUE
'RING w Sw _ o- - ~ - - -
ITS- zr4S14
_ 1 ♦ W NOTE. A OLRLDING U BA;,A OF 1W FPGw TNf CENTERL'NF Or Au
1 . s 'a lnt• 1. 2. 1, 4 C w Fl18JC POAOF, s ES'AAL15r+ED FCyt Al- LOT4 IN TI IS WKZMs,oN.. ..y-_.. _
. 7 \N b a E', bT Ce: [ tiH SLneT _ v ; .
n MA
b r JA•i• I - 1
. r57•s03e•~: o Air-.. rr
b A rrP O i 't!. 1
%
%
C J0, o' "ses•aa'w
' o4•w
IS UNPL 73,
ATTED _
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a
ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
d
OWNER/BUYER 4-1 -j Ie -I l E
ROUTE/BOX NUMBER Fire Number
•
CITY/STATE ~A 4"J"f ZIP
PROPERTY LOCATION:nU6iD,4, 4, Section ' T _9(1 N, R ( W,
Town of St. Croix County,
Subdivision ~I[ Lot number 5
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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 fI
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. y
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I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
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the standards set forth, herein, as set by the Wisconsin Depart- ~d
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoni ffice within 30 days
of the three year expiration date.
SIGNED
- Z-"'-
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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
iRVDUSTFiY, C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 . P.O. BOX 76
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/M~LOT NO.: BLK. NO.: SUBDIVISION NAME:
1/4 /T~9N/R 19E co) W !°.~i»~ J B - S-rz J 3,
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COUNTY: C~VPofdER=S/BUYER'S NAME: MAILING ADDRESS:
`~-•~°,'`:~~°.a'.a;-_.; L`"~:t,~1~` ~C>UT"C I
USE DATES ~OBSERVATIONS MADE R COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 4 r~ New ❑Replace 15 -
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL.: MOUND: II IN-GROUNcD-PRES'SIURE: SYSTEcM-IN-FILLHOLDIING TANK: RECOMMENDED SYSTEM: (optional)
V EU El J ZV EJ V El V DV El U El V EA -,~C~'~E~)~h;?~
If Percolation Tests are NOT required DESIGN RATE: [Floodplain, n
y portion of the tested area is in the under s•H63.(b), indicate: indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IPdLS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Md OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P_ 3N
P- Z 114 ,,-IU 313 t 2'
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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. 11"', t -n 1 _ LA
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1, 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 Wisconsn
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):
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CST SIGNATURE:, r
TRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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PORT ON SOIL BORINGS AND SAFETY & BUILDINGS
RE DIVISION
"DUSTY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS (H63.09(1) & Chapter 145.045)
DIVISION NAME:
LOCATION: SECTION: TOWNSHIP/Mt7Rti£fP-A-t+T~': LOT NO.:BLK. NO.7U
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1/4 1/4 /T ~.qN/R i~) E (or W
000NTY: OW /BUYER'S NAME: MAILING ADDRESS.
DATES OBSERVATIONS MADE
ce : PROFILE DESCRIPTIONS: PERCO LATIONJTESTS:
USE
NO. BEDRMS.: IculvilvIORCIAL DESCRIPTION
gNew ❑ Replace - - >
Residen L)
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IIV-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S ❑U OS U ®S EIU DS ZU ❑S
If Percolation Tests are NOT required TDESIGN 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-1{V6 S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH I#x ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
l,p UCu~vt= } 7J ~Y St O.~S' ul Sl I jZS, ~r tv,.
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PERCOLATION TESTS
ROP IN L-
TEST DEPTH WATER IN HOLE TEST TIME D WAT ER LEVE INCHES PE RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3
P-
P-
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P-
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PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate wale 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.
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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 Wiscor3sin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
TESTS WERE COMPLETED ON:
PADDRESS: (print):
CERTIFICATION NUMBER: PHONE NUMBERIoptionall:
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CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DI LHR-SBD-6395 (R. 02/82) - OVER -
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Cw _-'s n3-':e San.
H63.05 PLOT PLAN r
how:
Location of building served Dosing chamber
Septic tank Vertical horizontal reference point
Building sewer System elevation is
Effluent system' Well
Li- Replacement system area Prooerty lines w/in 50' of system
!JR- Distribution boxes r ~1 Scale or dimensioned
i° Pump and controls:
Mfr. & Model No. Vertical Lift Size Force Blain
Friction Loss T. D. H. Vol. Dist. Pipe Gal. per ;Lin. Gal. oer Cvc'-e
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Place check mark in appropriate box, indicating item is sho,,m on plot plan,be
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By the granting or approving of the above plan, or upon the event of a subsequent
p'_rmi t being i ssued,St.Croix county and the St.CroixCounty Zoning A-dm nistrator, doF
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination oversight, construction, or any may rL,< .,i r i T; or
F` stallat' n.
C.hP ~Z." !~-bout n+~ :snN;: ~r fines
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