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_ Form- S T C - 104
AS BUILT SANITARY SYSTEM REPO
OWNER TOWNSHIP Z T N-R~W
ADDRESS ST. CROIX COUNTY, ONS
f
SUBDIVISION LOT LOT SIZE ai~Glev
PLAN VIEW
Distances and dimensions to meet requirements of TLHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
-IV.
ter ,
\S
v
1,2
L~
HrI+
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 16D
Elevation of vertical reference point: 4Q2g.f, Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: / y~gp
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: j p3. j Z Tank Outlet Elevation: /CA i
Number of feet from nearest Road: Front, 1QSide10 Rear, 7 ~D feet
From nearest property line Front,0 Side, QRear 1 O O feet
i
Number of feet from: well J 5-0 building: 7Sr
(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: y Length: l,/L Number of Lines:
Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, ~JJ
~i Rear, O Ft.> a '
Number of feet from well: 71 SO /
Number of feet from building: 7 /pep'
(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: 7 - -7 Plumber on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.Q. BOX 7969 BUREAU OF PLUMBING
MA91SO :41 53707
• )tXJCONVENTIONAL ❑ALTERNATIVE Sfare Plan l)D Numbe
I
❑ Holding Tank ❑ In-Ground Pressure El Mound if assigned
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPEC ION DA •E
Paul Somers 717 N. Main St., River FAlls, WI
BENCH MARK (P-mane, reference point) DESCRIBE IF DIFFERENT FROM PLAN. R F. PT. LEV.: CST REF. PT. ELEV.
SE NE, Section 15, T28N-R18W, Town of Kinnickinnic
Na- )f Plumber. IMP/MPRSW N,) Coumy. Sanitary Permit Numbe,_
Daivd B. Fogerty 3289 St. Croix 64874
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQU10 CAPACITY. TANK INLET ELEV TANK OUTLET EV WARNING LABEL LOCKING COVER
0 PROVIDED. PROVIDED.
6t' DYES ENO DYES ENO
B YR OF ROAD. PROPERTY WELL BUILDING. JVENTTOFRESH
BEDDING. VENT DIA.. VENT MATL. HIGH WATER FNEMRES
? ALARM i LINEN AIR INLET'.
ET FROM , 0,1
DYES NO ie DYES " NO T i '
D
OSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
DYES ENO EYES ENO DYES ENO
GALLONS PER CYCLE: NO CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN PUMP A FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ITFN(II H DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH. LENGTH INOOF DISTR. PIPE SPACING,. COVER JINSIUE DIA -PITS LIQUID
BED/TRENCH d~ TRENCHES i MAS€RIA PIT DEPTH
DIMENSIONS }
GRAVEL DEPTH FILL DEPTH 1111ST1,1111 DISTR PIPE DISTR. PIPE MATERIAL. NO. S R. NUMBER OF PROPERTY WELL' BUILDING. VENT TO FRESH
BFIOWPIPES / ABOVE COVER ELEV ~F E EV ENp PIPE LINEI AIRINLET.
C1 FEET FR
( ~'l 4 L7L`I NEAR ESTO--w-
f
MOUND SYSTEM: v
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
D meets the criteria for medium sand. TIONS MEASURED.
YES ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ENO DYES ENO
DEPTH OVER TRENCH:'BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
CENTER EDGES.
DYES ENO DYES ENO DYES ENO
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. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV. DIA. ELEV.. PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
EYES ENO EYES ENO
COMMENTS: ( PERMANENT MARKERS: OBSERVATION WELLS: UMBER OF LROE ERTV WELL: BUILDING.
0 FEET OM
A DYES NO DYES ENO 1NEAREST-----)iP-
V1 J
~ I
7-1
0
Sketch System on L ~5 Retain,in county file for audit.
Reverse Side.
SIGNATURE: TITLE
DILHRSBD6710(R.01/82) F •
P
wlscon5- APPLICATION FOR SANITARY PERMIT
a jZ. COUNTY
(r DILHR r
oERRRTmEnT of
(PLB 67) UNIFORM /SANITARY PERMIT #
OOSTR4,LR90RGHOmgn RE LR
In TIOnS / I V
-M I -I /I
-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 re se side for instructions for completing this application. PLEASE PRINT
PRO Y O ER MAILING ADDRESS
P OPERTY LOCATION CITY:
114 /4, S VILLAGE:
S N l8 E (Dr) TOWN OF: I " " G
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE QF BUILDING OR USE SERVED AZ -
~yn ~a
1 or 2 VOt p~l/0~~~30 I
Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
ham/ New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System L~ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
It/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
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: C
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):
z
ys Private E:1 Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
of Plumber (Print): ture: MP/MPRSW No.: Phone Number:
o Re
er's Ad res
Name of Designer'"
~ p1J
A CA/Iiiic~ I W - -4) 'X -
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~/"n 1,( L9: s jfz,/ ~l v J ❑ Owner Given Initial
0 ( c Approves Adverse Determination
Reason for Disapproval: L
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 fln v, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be a;
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.
,r
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/contractor,("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property
Location of Property s _It Oel,~C 14, Section T N - P. W
Township
Mailing Address 71L~
~ti
T
Subdivision Name
Lot Number `
Previous Owner of Property
Total Size of Parcel 3 Cc' 1ii-74Ct-f
Date Parcel was Created SC6 rmCIdL-l> V~'~-j
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed e D
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) eenti6 y that att d.tatemente on -thi6 6o4m ane .tAue. to the bed.t o6 my (oun )
knowledge; that 1 (we) am (ane) the owneh(d) o6 the pnopenty de c i.bed in ttUA
.in6o4mati,on 6onm, by vi tue o6 a wavLanty deed neconded in the 066.ice o6 the
County Reg.iAteA o6 Deedd ab Document No. - and that I (we)
pnee en ley own the p.upoe ed 4ite bon .the a ewage poba~e y6.tem (o& I (we) have
obtained an eabement, to nun with the above debeni.bed pKopeAty, bon the
con,6tAueti.on o6 eaid 6yb-tem, and the came ha6 been duly neconded in the 066ice
o6 the County Regiz ten o6 Deedd, ab Document No*. _?o ✓
SIGNATURE OF OWNER SIGNATURE O CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
WIN
N olow Yo Linder
of the} of
60
?F, " nesoriptiont 1 parcel Of land located IA the
1: Iloo +oa 16 1'28)~I, R181t, T vz of linalokinsio, St. Croix county,
V1844nsin described as folloxst CoMenoirag at the East i ooruer of
said boution IN thenos 5860211W 1067.370 to the point of bsginr~is~gi
nas X2040 V 251,00 along the Northerly right of way Ii of County
t gighway •J°' as -shown on the r9co d right of nay pla 'Tor
n►swlsiou q6b ltoo 4335 of the State HightwaY emission Of viseonsiA;
tbsnoe W alIV 2149701; thenoe W83°50 8 248.001; thence 137080'Z to
Otis point of beginning,
i
~J*sd A* d` Xurti
Ift
f sWlptlons A parcel of land located in the W* of the of
seasion 150 , 816WO Town of [inniekinnic 8t. Croix Cotunty~ ,
Ms described as tollowe a 00=0nolGg at the last k 40ttwr of
Art n1w
_
tin M thones 06010 IV 8170?21 to the point of bo
f ; %bsn" 8820401V ~150o0+01 along the Northerly right of tp7 line of qty
w k Higb rag as . gbM on the recorded right of way plat for
f fly io11 Job No, 0583 ` of Rt to $1 ay ftss"81911 of 111-1100118111' e
,
S f f ,
g 20908511 thence NW50 8 bO.Ob t3ens+o ~2AI8 ll0d.b4~ to
point of begs .
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501,1
. + 2+48.00 N83-0
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250.05
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GLENN '~i►.!.INDE + FRED A. KURTZ
Irp
r x.021 ACRE$ 1.119 ACRES
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Y_ OF
, S624401N SEC 415 20N;RI~#Ilf
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on rbpiaterod Mieceaaia Lind 8u►oyor9 do hobby cortity that,; 19 2 a+►r'oyed the above. described sad napped property acoor" to the
w
l6 nt y dinroaaloaod roprereatatida to ~lo of
ot~'icial *eoordo and that this aaoot~ar ng sap is a cor~ro
t b~p~sdaue,, that all buildimes se uproveOOats lie wholly withia tho boundary lines, Dad that
au, gsoraeoemouts, by adSoiaia8 ewa rs appoar from said aurvoy.
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
OWNER/BUYER
ROUTE/BOX NUMBER 2/71y, Fire Number
CITY/STATE ,~~~/l ZIP PY/~-y1
PROPERTY LOCATION: AV Section , T N, R_W,
Town of St. Croix County,
Subdivision Lot number
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 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
H
the standards set forth, herein, as set by the Wisconsin Depart- I'd
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zon" Office within 30 days
of the three year expiration date.
. d'410
. SIGNED,
ATE~7
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
IJVDUSTRY, DIVISION
N
LABOR A PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS 1 / MADISON, WI 53707
11H163.09(l) & Chapter 145.045)
LOCATION: SECTION: OWNSHIP UNICIPALITY: LOTNO.:BLK.NO.:SUBDIVISION NAME:
S 1/a /T N/ E (o I
OUNTY: OWN 'S/BUYER'S NAME: A LIN ADDRESS:
A, S;
USE
NO. BEDRMS.: COM MERCIAL DESCRIPTION: DATES OBSERVATIONS MADE
P
Fiesidence 7 New ❑Replace ROFILE DESCRIPTIONS: PERCO LATION TESTS:
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
If Percolation Tests are NOT required DESIGN RATE:
under s.H63.09(5))1b1, indicate: If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF S WITH THICKNES ,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF O SERVED (SEE ABBRV. ON BACK
B
-C
O > r : 2 r s 3' Ad,
s.
B- 2-
2 >
Zn e S / n w
B- /z~lr 5W 1AZ&ell IS ;7 xz
B 6 / 0
? j / fn 7'/7n 7dS /.7r~
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. DROP IN WATER LEVEL-INCHES RATE MINUTES
PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P / 37 Z
P-
P-
1 ~ z
P-
P
T
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
zonta! 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
1
b
i
,
i
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,
,
I 3
z
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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.
a(pNrintl:
TESTS WERE COMPLETED ON:
t
S:
CER IFI TION NUMBER: PHONE NUMBER (optional):
)y _
ST SIG T R
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D!I_HR-SBD-6395 (R. 02/82) - OVER
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