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Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
~c• TOWNSHIP SEC. Tn?~ N-R ` W
P
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION ll,~ ¢ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of II.H,R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Q 0,
\D
LL)
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used eld lts 32
Elevation of vertical reference point: /ot), Proposed slope at site: d
SEPTIC TANK: Manufacturer: < Liquid Capacity: 6 el-r
r
Number of rings used: d N L'~ Tank manhole cover elevation:
Tank Inlet Elevation:
6, ~2 Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side,gRear, O rCp feet
From nearest property line Front,O Side,O Rear ,t7\ feet
• d f
Number of feet from: well _ building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: L-~ctjt"_3•T Liquid Capacity:
Pump Model:Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: ~J jl l Bottom of tank elevation: /C J
Pump off switch elevation: Gallons per cycle:
,g--~ae'fp~
Alarm Manufacturer: ) ,Z-;eE-C-7%S J Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, Rear, Ft.~
Number of feet from well: J
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
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: S Plumber on job:
License Number:
l
3/84: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 _
❑CONVENTIONAL ALTERNATIVE state Plan ID Number:
(lf assigned)
❑ Holding Tank ❑ In-Ground Pressure Mound
NAME OF PERMIT HOLDER: ADDRESS OF PER HOLDER: INSPECTION DATE.
Gneg Ro"vt R. R. 1, Hammond, W1 54015
BENCH MARK (Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SF NE, Section 9, T28N-R17W, Town o6 Heaaant Vattey
Name of Plumber. MP/MPRSW Nn.. County. Sanitary Permit Number:
LyZe Myeu 6219 St. Cnoix 74958
SEPTIC TANK/HOLDING TANK:
MANUFACTU HER. LIQUID CAPACITY. TANK INLET E EV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
f` PROVIDED. PROVIDED.
❑YES ❑NO ❑YES [:]NO
BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPER TV WELL: BUILDING. JVENT TO FRESH
C ` ALARM LINE ~J AIR INLET FIE ❑YES NO tp 1 ❑YES
DOSING CHAMBER: w li
MANUF\ACTUHER. BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTIIHEH WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ®NO n
v it ®YES ❑NO J YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. tNUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN ' uNE6 I AIg NLET
PUMP ON AND OFF) YES ❑NO NFEET EARESOM .J Lv
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 FNI 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 PIPE SPACING COVER JINSI OE DIA 1t PITS IL1QUID
DIMENSIONS TRENCHES MATERIAL' PIT DEPTH'.
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
BELOW PIPFS ABOVE COVER ELEV. INLF i ELEV. END PIPES. FEET FROM LINE. AIR INLET.
N EAR ESTi.
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-
_KES ❑NO meets the criteria for medium sand. TIONS MEASURED.
I/~Y
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
YES ❑NO YES ❑NO
DEPTH OVER TRENCH; BED DEPTH OVER THENCH BED 7r=;~- SODDED SEEDED MULCHED
CENTER / C EDGES. ^ "
ll ❑YES NO YES ❑NO L-ACMES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS 5 14!
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV o y ELEV ) DIA. ELEV.' p PIPES DIA.: 1
ELEVATION AND J l
DISTRIBUTION da4r?jam
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
y t' ' ) PLANS
3 .
YES ❑NO ''❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE r'
LYES ❑NO [~JYES ❑NO NEAREST d E:l/ L
Sketch System on Retain in county file for audit.
Reverse Side.
ENATURF--TITLE,_.r
F y*.
D I L H R S B D 6710 (R. 01 /82) _ r y"
wisconsin APPLICATION FOR SANITARY PERMIT
~ DJT LHR
(PLB 67) COUNTY
nof
MM= InOUSTq'g6HUTgnqELFiTIOns UNIFORM SANITARY PERMIT #
-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
PROP TY OWNER MAILING ADDRESS
~'rt r3
PROPERTY LOCATION I F
CITY:
1/41,' 1/4, S N, R E (o W / TO AGE: C`
LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME✓ Zr F
fir IS NEA EST ROAD, LA E OR LANDMARK
STATE PLAN I.D. NUMBER
7- • ~ ' /-)Cx z GX
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Re air
x Replacement Pm p
❑ 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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound ❑ In-Ground Pressure
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber t
Manufacturer. 7-
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
' 9Z Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Namg of P umber (Print):
" _ Signature: MP,JMPRSW No.: Phone Number:
Plum er's Address:
Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signatur of Issuing Agent: Fee: Date:
❑ Disapproved
p ❑ Owner Given Initial
/Q ~r~ Approved
Reason for Disapproval: Adverse Determination
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.
p
DILHR PLAN APPROVAL Safety and Buildings Division
~m.. OVAL
Bureau of Plumbing
P.O Box 7969
General Plumbing Plans Madison, WI 53707
Private Sewage Plans Telephone: (608)266-3815
Plan Identification No.
r I
Gallons Per Day
S
17
17
75 PRIORITY PLAN REVIEW ONLY
Plan Review Fee Received
Petition For 'Variance Fee Rec.
Project Name Project Location Street No. or Legal Description
S140- 4/
County
❑ City ❑ Village Town of:S7
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.
FOR PRIVATE SEWAGE PLANS: (1) (2) (3a) (3b) (4D)OC 4b) (6) (7)
This approval will expire two years from the date approved r ifa 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 onhv. All other system reviews must be
submitted to the Bureau of Buildings and Structures.
Comments:
By: 7
7
James Sargent
Bureau Director
If Questions Plans Appr ved By: Date Approved:
Contact y
cc: rivate Sewage Consult ❑ Plumbing Consultant !--I Environmental Health
ounty ❑ Local PI ❑ Facilities Need Analysis Section
❑ UW-SSWMP ❑ Plumber Department of AgriculWre
D1[ HR-SBD-0099 (R. 01/85) 1 1 Owner f-] Other
~YLF ;5 PA-14, ZR11VG Rk Ra i F~
H-T fox Y7 4
'BbYCEY (y! 1., 6 y 7
M? 6214
SIGNS D
?Ao,T9cz' NA mE
i T. SE-fj Nk" t Sm. 4
t-'l-t~lsAnrt- VAuG y ~w ~ps~~ P
ST e;zoix '(AUAT'-f , W LS 1h
. N
~GoT f L A N
ti NC
It's
t~ IN
~ ~ fie. , ,.►Knu ri.n ~ o Co ...T-
r AREA
O
D ' S NGi mhg- q = )00.0
A'iAak ON BAst A jE-jy-^ GuAlc 3 PE~Raom
ABoJE eEmwxn si.Ae3. NoutE
I = yO' ScA~E ` '
WELL
i
:c` .
_ y
Page Of
Straw, Marsh Hay, Or
Synthetic Covering
Distribution Pipe
Medium Sand
H G
Topsoil F
E D
3 ,b
5 % Slope
Bed Of ZM- 2 %2 Force Main Plowed
Aggregate Layer
8FD ELCV. 7- ,6 D / Ft.
Cross Section Of A Mound System Using E Ft.
A Bed For The Absorption Area F ~S Ft..
G Ft. 671-2 A Ft. H Ft.
Signed: B Ft.
License Number: G'-;2 K /a Ft.
Date: L Ft.
cS'E®r a ~ /9~ s
Ft.
4t-e a to ~4o n I _.a i Ft.
W
L _ _
Observation Pipe---,,,
K
101
MANRE~~~~p~1~- -----'I
L~ggR AN pitC3S--------- ----------------------+I Force Main
of IN S TY A -
u 1i1~D
CO ftES 1rfibution Bed Of z - 2 zPipe Aggregate
I R cEivE
Ob ervation Pipe Permanent Markers !a,
P l EALI
Plan View Of Mound Using A Bed For The Absorption Area
Page _ Of -
Perforated Pipe Detail
0
End View
))Perforated
End Cap) PVC Pipe
i . ""\o'o once
pie Holes Located On Bottom,
S Are Equally Spaced
S
P
PVC Force Main
~ .7
/Q PVC
;s t~+nifol~[Pipe
`Alternate Position Of
it ion on
P1 Force Main
Lost Hole Should Be 1 H~M~ti~~ = y`!~ r
Next To End GQ D ~V1LC G5
isth
t t' i yout P
?3_ FtQ [3 1
~4~PRIMEN V1 \0 5 g~E GpRRE ~ ~ R
S"
/ X Inches
Y 21 Inches
Signed: Hole Diameter y Inch
Lateral 11 Inch(es)
License Num er: Manifold Inches
Date: ~'~~T a! _ /9,P Force Main 3 Inches
# of holes/pipe wInvert Elevation of Laterals 9y,/ Ft.
/ RECEIVED
OCT 0 3 lc,
Ri_ l lh4P1n1f; RUREAU
• PAGE OF
PUMP CHAMBER CROSS SECTION AA1D SPECIFICATIONS
VENT CAP
4"C.I:-VENT PIPE
WEATHER PROOF APPROVED LOCKING
25' :-ROM DOOR JUNCTION BOX MANHOLE COVER
- ,
WINDOW OR FRESH I2"MIU. I
;'.TAKE
GRADE
I 4" MIKJ.
15" MIN.
CONDUIT--
f8"MINI.
INLET PROVIDE
AIRTIGHT SEAL I III ~
~
( r--r
I ~ I
APPROVED JOINT A I I I ( APPROVED JONTS
W/C.S. PIPE I III W/C.I. PIPE
EXTENDING 3' I II ALARM EXTENDING 3'
ONITO SOLID SOIL f3 I I I ONTO SOLID SOIL
I I
ON
ELEV. FT. naffs
PUMP OFF
RCL''
F{ Ar=~+ CONCRETE BLOCK
'C R`~ 4 gU1L
r✓FP~~~ ERM N TANK MANUFACTURER HAS SUCH APPROVAL
pN
SEPTIC E caEE C~RRESP S PC C I F I C A T I O U S
DOSE
TANKS MANUFACTURER: u1-1- 02 - WMBER OF DOSES: / PER DAy
TAKJK SIZE: Roo F'DIJ )IF))
GALLONS DOSE VOLUME
ALARM MANUFACTURER: "TAAlk AGEr2?' INCLUDING BACKFLOW: GALLONS
MODEL NUMBER: /a _ y w CAPACITIES: A=FLINCHES OR 5f2 GALLONS
SWITCH T.4PE: InE22.GU0L~/ 5 =-,2. QQ INCHES OR -qO GALLONS
PUMP MANUFACTURER: -el,Oli e-0 G = G IMCHES OR /3-7 CALLOUS
MODEL NUMBER'.3ff85_ l2eO 3M D= L.o IMCHESOR ~IQ GALLONS
SWITCH TYPE: lfa ii N~OTE7 PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE 7o GPMCQn"~ INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN! PUMP OFF AUD DIS R~gU'flom PIPE. . -3 FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . , . . . . , 2.5 FEET RECEIVED
+ 75' FEET OF FORCE MAIN X FYo FTFRICTION FACTOR.._:QL_ FEET I S3 y
OCT 0 3 1
TOTAL DYNAMIC HEAD FEET
~j
a
UREAU
J ~3
INTERNAL DIME.WSIONS OF TANK: LENGTH ` ;WIDTH ;LIQUID DEPTH y_
SIGNED LICENSE 'NUMBER: Z9,,' Ga~~ DATE: 3 4 d57
,EGG RO~ir,-g
_ /oo. a ~ " ~6oy~ eGQONN.U G~Y~L Z . G '
/•vsTA« s~=~Ti~- T~~vt o.~ /.S ' ~lstos✓ G.tpO~ Du-Z' aFrY~tc,2'
o?' 7^o G 4,
D o P -T-F{ 0,0 ECG K S.T. &n-c-, u n4 9 N 1. ,
LL ro
sca6~ Co~ricl tvsO71 0-~,
Q. Z
t ~t T3 ccT f ± , t~ e C LLV (S-M O'u = ~l
q o,$
~ X l = 7r~ z G~,o~ Des ~A24~-`~
f=.~~Ul`. ~o-ss /,08 ~ioo 3.. S~1ED y'o !~Y. c .
RECEIVED
0 3 1985
RUREAU
7
/
Bulletin CL2.1A
July 8, 1983
For Homes
Farms
Trailer courts Model 3885
Motels -
(Supersedes Model 3870)
Schools
Hospitals Submersible
* Industry E'"usift PUM Effluent Pumps
Effluent Systems Pump Specifications
anywhere effluent Solids Handling Capability to
or drainage must be Discharge Size
disposed of quickly, ';P-
quietly and efficiently. Semi-Open Impeller
ianR design. threaded or-, Sr1af; -re? rhaSe
units use impeller Idcknut to prevent accicienta,
pack-oft Pump out anes on cac:<slde of meeiler
`or protection of mechanical seal
Casing
Volute type for maximum efficiency-
Heavy-Duty SOIIdS Handling Stainless Steel Fasteners
Series 300 stainless steel for corrosion
Dependable Capability to 1/4" esi,tance
Mechanical Seal
Cermlc vs. Carbon seating faces, stainless steel
spnrg and Buna N elastomers.
Maximum Temperature
1/3, 1/2H.P. 60 Hz 160°1
Single Phase 115, 230 Volt. - Capable of Running Dry
without damage to components.
Motor Specifications
1/2, N, 1, 11h H.P. 60 Hz Motor Fully Submerged
Single Phase 230 Volt. Three nldn grade turoi,,e o1! for permanent ;,cnca-
p !ion of ceanngs and mecnanlcal seal and
Phase 208-230, 4 80to O efficient neat dissipation Motor sealed 'ro.rr
envirorment by rugged cast iron enciosure-
0 1gU Bearings
Heavv-Jury all call bearing, constn c;ion
Stainless Steel Shaft
Series 1300 stainless steel for corrosion
esjs;ance Threaded shaft.
Single Phase Units
90 f. All single pnase nits -aye
overload protect : i vrn autJmatic
80 Three Phase Units
' Overload protection in starter unit. 2C
?
70 y 460 volts Threaded shaft 60 Hz oceraiir ry
W
Power Cord
W -
60 ` Water and oil resistant. Epoxy seal on „xc
o acts as a seccndarv moisture carrier in case
a
w damage to outer jacketing. Corrosion rests ;
= 50 a
V gland nut.
Yt + Single Phase Units
C 40
Z - HP models egwpped with of '6 0
WEI&i(I ,rK • r SJTC with 3-prong droucdlnd plug
a 30 models equloped with 15 of 14 3 STO coy: er
a ~r ! cord.
O 20
' 10 = "c• SPECIFICATIONS ARE SUBJECT TO CHANGE
4 a t WITHOUT NOTICE.
0
0 10 20 30 40 50 60 70 80 90 100 x 110.. 120 rnGOULDS PUMPS, INC.
GALLONS PER MINUTE u SEIl FALLS NEW FORK 13148
LINDSAY BROS. CO.
LIQUID LEVEL ALARMS
FOR WATER AND SEWAGE EFFLUENT
Series 200
2000-1 is a warning device for si aling a high level alarm in
a pumping system.
` A PM20-Float acts as the nsor. It comes with a standard 20
feet of cable, normally en or normally closed contacts, and
is available in Pipe- unted, (P type). Longer cable lengths
are available upo request. A watertight connector is fur-
nished for dire wiring of the Roto-Float to the Alarmpak
panel.
The alar panel itself sounds a buzzer in response to a high
or to evel condition. A pushbutton silences the audible
a m while the door mounted panel light remains illuminated
or as long as the alarm condition persists. The enclosure is
available for indoor or outdoor use, (Series 2000-1 and
2000-3, respectively).
Dimensions: L x W x D Specifications:
u N Enclosure 6-9/16 4-5/8 3-3/4 -80 db. @ 10 feet .16
V 60H --r / Mounting 6-1/32 Buzzer
Z -SPDT Relay 12 Amps @
Ll r--1 3 RI / 113 V.A.C.
E2 -Mercury Switch rated 4.5
L- - SILENCE ; Amps 115 V.A.C.
ALARM RI ✓
CONTACT 9L'ARM
( ROTO-FLOAT) ALARMPAK Series 2000-1
R~
Lindsay
RI Product Model
Number Number Description _
AUDIBLE 496030 2000-1 115 V. High Level Alarm
ALARM--// 496022 PM20NO Float F/20 Ft Cable
A NW A s
t LISTED]
Model: 101 HW (High Level Alarm) N.O. Switch for
Sewage Holding Tanks, Lift Pumps, Sump
Pumps etc.
101 LW (Low Level Alarm) N.C. Switch for
w Cisterns etc.
Waterproof cable splice kit included.
Voltage: Primary 115V .60 Hz. secondary 12V .60 Hz.
Wafts: 5 Watt Alarm Condition
Alarm 6 in. x 4 in. x 2.5 in. Metal Enclosure with line
ALARM SENSOR Panel: cord or electrical knock out for direct wire.
PANEL FLOAT Float: 3.18 in. dia. x 3.875 in. long
Noncorrosive ABS Plastic with internal stabilizing
weight.
3 egg For use in Liquids up to 150°F.
s 101 HW N.O. Switch 5 ft. Float Cable
101 LW N.C. Switch 8 ft. Float Cable
Lindsay
Product Model
Number Number Description
526339 101-HW High Level Alarm
211
~ DILHR
n PLAN APPROVAL Safety and Buildings Division
Bureau of Plumbing
P.O Box 7969
General Plumbing Plans Madison, WI 53707
Private Sewage Plans
Telephone: (608)266-3815
Plan Identification No.
Gallons ay
Per D
Y n - PRIORITY PLAN REVIEW ONLY
J
Plan Review Fee Received
Petition For Variance Fee Rec.
Project Name -
Project Location - Street No. or Legal Description
City El Village El Town of: Cou
The plumbing plans and specifications for this project have been reviewed for compliance with requirements. This approval i>
based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This appro
is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by t
city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set
plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can t)e
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.
❑ 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:
argent
rector
'Is Plans Approved By:
Date Approved:
Cc: CI Private Sewage Consultant ❑ Plumbing Consultant ❑ Environmental Health
1 County ❑ Local PI ❑ Facilities Need Analysis .Se(
tion
UW-SSWMP ❑ Plumber
ss) i ~ _ ~~epartmcrt; or` t;r~cuiture
Owner ❑ Oth, r
1
°F REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
CATION: SECTION: UNICIPALIT LOT NO.: BLK. NO: SUBDIVISION NAME:
'/a,t~ '/a /T N/R! AIr l&1'r- z t' ~1
COUNTY: OW S/BUYER'S NA EAILI G ADDR ^
6) i
c It /c"wsoftc,
~~l Cvr n.m a-. l 6 y
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI E DESCRIPTIONS: PERC LATION TESTS:
~YJ Residence ❑ New L7Replace I /0. l~
RATING: S= Site suitable for system U= Site unsuitable for system
CON~VENTIOI~AL: MOU_Np: IN-GROUND-PSSURE: SYSTEM-I~~LHOLDING
COMMENDED SYSTEM (optional)
OCT
If Percolation Tests are NOT required DESIGN RATE: If an 1 I any porti
on of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
:
4 ~ I -
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
l s
Bet -i__3 Si
15 Al-7 .17 5 i c~1~cx .
B -~3 ,d_5 Zoe&u4 IM,94 12'Ago s,
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P RIOD 1 ERIOD 2 P RIOD 3 PER INCH
P_ _73 -0
s
P-C;t c;? 307
/<3 A 1-33,96 17
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.
S EVATION qQ, 7_~5
f
~o 49 .5.
,
N
'44 /00 13 rf-\
u? 'rat
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 7RECO7 L ~ D ON:
ADDRESS:
n CERTIFICATION NUMBER: PHONE NUMBER optional):
~3~
CST §It7
VAT URE: A
r
r
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
`a E ,a
r~Fl .~l ci33 r ~~a €i _ _ ~ G ,z;.3 ~ 'fib _ ,-.F~ti -
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-n 11
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r t c ~E
'',st -?r ne, C €T "i env cor1S_1t _.n. t t.E ,.n'
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 e',,-SP.x!~
Location of Property Section , T-;~ 3/ N-R W%
Township e
Mailing Address
.vim.
Address of Site
L," S
k
Subdivision Name
Lot Number
Previous Owner of Property ~'c Af p7 a /V d~ lz2,
Total Size of Parcel
Date Parcel was Created ~~Le.I7e -2 1 % 1
s
Are all corners and lot lines identifiable? Yes t' 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 THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) celtti6y that alt Statements on thii6 6ottm cute tAue to the best o6 my (ouA)
know.tedg e; that I (we) am (aAte) the owneA (,s) o6 the ptto pets t y dens n iib ed in this
in6o. mat on 4ottm, by vi tue o6 a waAAanty deed ttecotcded in the 046ice o4 the
County Reg.usteA o4 Dee& as Document No. ' ; and that I (We) ptte~s ent y
own the pttopotsed site Gott the sewage duspos system (ott I (we) have obtained an
easement, to tun with the above descAibed pttopelcty, Gott the con,6tltuction o4 Aaid
,system, and the same has been duty tteco&ded in the 046ice o4 the County Registert o6
Deeds, ass Document No.
SIGNA OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
T
DATE SIGNED DATE SIGNED
S T C- 1 05
a
r H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
9
OWNER/BUYER y /
7
ROUTE/BOX NUMBER ~~11x Fire Number
CITY/STATE ~I I , ZIP
i Section N R W
PROPERTY LOCATION:, C Z, A 1~,
Town of 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. '3
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- 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 l
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.
SBD 6678 (R. 08/83) (Plb 100a) (Wis Stats. S. 145.02)
Detach And Return STATE OF WISCONSIN DILHR
Upper DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
Any Return Correspondence 201 E. WASHINGTON AVE. RM 141
P.O. BOX 7969
MADISON, WI 53707
608-266-3815
DATE: PROJECT:
r , NE, 9,28,
it Rleasan
PLAN ID.
DETACH HERE
- - - - _ - - - - - - - - - - - -
PROJECT NAME PLAN ID.
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 $
❑ 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 be held in abeyance.
1. Plan Submission ❑ Soil boring and percolation test data on 115 completed
Additional information shall be submitted in duplicate unless by Certified Soil Tester. (1 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 ILHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required. (1 copy)
Administrative Code. ❑ Affidavit enclosed. ❑ Condominium declaration. (1 copy)
❑ Plot plan showing location of land parcel (distance from
nearest road intersection, etc.), lot size and all distances from IV. Holding 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.
❑ Holding tank agreement signed by owner and local
II. 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 and percolation test data on
❑ County onsite required. (1 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. (1 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 Form by 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 if state approved. ❑ Total area filled (fill to extend 20' bevond 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.
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M ST. CROIX COUNTY
WISCONSIN
a , Prt~rq ZONING OFFICE
? y, III , 796-2239 (HAMMOND)
I 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
September 27, 1985
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An onsite investigation for the Greg Rousar property located in the
SEA of the NEB of Section 9, T28N-R17W, Town of Pleasant Valley,
St. Croix County, revealed suitable soils at a depth of 25 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,
Cho
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/ XRX~ XZXXJ€XX
SE 14 NE 14 S 9 T 28 N/R 17 XWOW Pleasant Valle St. Croix
Street Address: Subdivision: County:
Landowners Name: Mailing Address:
Greg Rousar R. R. 1, Hammond, WI 54015
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:
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
r DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location SE 1/4, NE 1/4, Sec 9 T 28 N, R 17 XK W
Town ouuMucpal1W Pleasant Valley Street Address
Lot No. Block Subdivision
Landowner's Name: Greg Rousar
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 num ers sueU-fo you.)
]one of the applications needing a quota number. The quota number assigned to
this application is - -
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.
1J for an application on file prior to February 1, 1980.
L]for 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:
Da 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 $1 re
County Official
Title Assistant Zoning Administrator Date September 27, 1985
DILHR-SBD-6158 (R 12/82)