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r _ Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP T,~ . , N
SEC. -R j' fW
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT jLOT SIZE 1-771 ~n
PLAN VIEW O %
n KA
Fri
M17 oc~C-:7
Distances and dimensions to meet requirements of I1RR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM cn
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INDICATE NORTH ARROW
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BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Prop f~'os s ed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: j =/,Y~ /Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,Q Rear, O feet
.From nearest property line Front, 0Side, 0Rear, O ~.J feet
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: Liquid Capacity:
Pump Model: Pump/Sip on Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
s
Pump off switch elevation: Gallo 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: 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 Pt
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
tt i l
Liquid depth: Bot o of seepage pit elevation:
Area Built:
Has either a drop box O or dis ibuiion box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation Hof bottom of tan':
Elevation of inlet:
% i
Number of feet from nearest property li Front, Side, O Rear, OFt.
Number of feet from ell: I~
Number of feet from bu' ding:
Number of feet from neare road:
Alarm Manufacturer:
Inspector:"~6
Dated: Plumber on job: License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.Q. BOX-7969 PRIVATE SEWAGE SYSTEMS DIVISION
'
MADISON, WJ 53707 BUREAU OF PLUMBING
RXCONVENTIONAL OALTERNATIVE state Plan 1,D Number
Il
Holding Tank O In-Ground Pressure O mound t asslgned)
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPE DATA 1 d, Richard Jacobson R. R. 1 Hammond WI 54015 /v 1p1/"
BENCH MARK (Permanent re to rence point) DESCRIBE IF DIFFERENT FROM PLAN REF. T. E LE V.. CST REF. PT. ELEV
_NW- 1, Section 19, T28N-R17W Town of Pleasant Vall1_ey__ _
N-,-)t Plumber. IMP,MPHSW N,, Sa,_,,-y Pe,m,t N,umhe
Dale E. Hudson 6629 Ist. Croix 69667
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY
TANK INLt ELEV TANK OUTLET ELEV WARNING LABEL LOCKING COVER
7 PROVI ED PROVIDED
" f ' ~L i / YES ONO OYES ONO
BEDDING. VENT DIA VENT MATI HIGH WAr R
ALARM M NUMBER OF Rono PR PERrv WELL euILDING VENT TO FRESH
NE 1 4 AIF HVL@T
NO FEET FROM u 1
YES O NO NEAREST l
L
_J YES
OSING CHAMBER:
IMANUFACTURER JBEDDING. I OUIDCAPA(:I IY =C10)'NTROLS WARNING LABEL LOCKING COV ER
PROVIDED PROVIDEDOYES ONOYES ONO
GALLONS PER CYCLE: PUMP ANDOPERA[ IONAL NUMBER OF PH!)PFHiY WELL BUILDIN(, VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NF I AIR INLET
PUMP ON AND OFF) OYES LINO NEAREST--)Ili
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing . , ,,In1,F (L H 41Ar1 HIn1 AND MAHKIN
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:
LNIDTH LENGTH No OF )ISIH PIPE SPAI]Pt COVE I, If.511:F DIA »PI iS LIQUID
BED/TRENCH
j rHeN+FS to/ri~lnl.
DIMENSIONS PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTR PI E DISIH PIPE DISTR. PIPE MATERIAL NO;f I.IH NUMBER OF PROPERTY W=11~L VENT TO FRESH
BE LOfVPIPES ABOVFI EV INf f PIfELINE AI INLETFEET FROM NEAREST?../
MOUND SYSTEM: j
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.
OYES NO 1
SOIL COVER TFXTORE H 1nNINI VARKIliS T BSEHVATION WELLS
JYES _ ONO -OYES ONO
DEPTH OVER THENCH BED DEPTH OV FH TRENCH RFIJ I)I TIT` OE T(1PS()IL Sc)I)I IFD OFF OF I) JMULCHED
(CENTER EDGES
I_ OYES ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DE PT II BF LOW PIP( FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD :jANITOLD MATEHIAL NO DISTR DISTR PIPE UIS
ELEVATION AND ELEVELEV DIA PIPES DIA
DISTRBUTION 1
INFORMATION HOLE SIZE HOLE SPACING OHILL EO COHRFCOVER MATEHIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES DYES ONO
COMMENTS: PERMANENT MARKERS OBSERVA TION WELLS [NUMBER OF PROPERTY WELL BUILDING
FEET FROM LINE
i OYES i~NO LJYES NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGMA URE TITLE'
1
DILHR SBD 6710 (R. 01/82)
r
w~-`°"5'" APPLICATION FOR SANITARY PERMIT f/1
~ ~
~ ®ILHR s"- COUNTY
0 oE:xagr irmtov (PLB 67f
#
mousTav, Laeoa s Human gEi.gT101'1s UNIFORM SANITARY PERMIT
1~ 9 ~7
-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
~G
PROPERTY LOCATION
1/4 1/4, S N, R 1'71 (or w TOWN F: r~
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST R07, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
AIX
TYPE OF BUILDING OR USE SERVED L - l S a
1 or 2 Family Number of Bedrooms: -3 ❑ Public (Specify): /d. ,
THIS PERMIT IS FOR A:
❑ 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.
X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill El In-Ground Pressure U Vault Priv
y ❑ 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 /f7oc~ X
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Pref a Steel Fiberglass Plastic
Gallons Tanks C Crete C ucted
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
/Q IF -7- qu 9~ Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber IPrintl: Signature,/' MP/MPRSW No.: Phone Number:
Plumber's Address: / Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved Z
L'k?Approvod ❑ Owner Given Initial
1C t~l Adverse Determination
Reason for Disapproval: or V
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
1 _
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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 k" "C- Z-' 0/
Location of Property, Section T N - R % 7 W
Township
T
Mailing Address ~ Z/ 2i d ff) j j
Subdivision Name
Lot Number '
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume L and Page Number &.O as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3.- Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTy OWNER CERTIFICATION
I (We) ee ti6y that aP.e statements on this 6onm aAe tAu.e to the best o6 my (ouA)
know.ee.dge; that I (we) am (aAe) the owneA(d) o6 the ptope,4ty desnibed in this
,in6onmation 6onm, by viAtue o6 a waA&anty deed Aeeon.ded in the 066.iee o6 the
County Reg-iaten o6 Deeds as Document No. 37%.5-,/ / ; and that I (we)
pnesenttey own the proposed site bon the sewage pos system (on 1 (we) have
obtained an easement, to Aun with the above descAibed pnopenty, bo& the
constAucti.on o6 said system, and the same has been duty Aeeonded in the 066.ice
o6 the County RegisteA o6 Deeds, as Document No.
i
SIGNATURE OF OWNER SIGNATURE OF 0 R (IF APPLICABLE)
c-
66
DATE SIGNE DATE SI D
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
U
St. Croix County
c7
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H
OWNER/BUYER
1'~lir (~GICCi 6S~%t2 rn
ROUTE/BOX NUMBER Fire Number
C I T Y/ ST A T E Z t 1, J~
f
PROPERTY LOCATION: I~CT/~a> iGl _'a, SectioT Z=N, R ;7 W,
Town of St. Croix County,
Subdivision /XA 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. o
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- w
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.
S I G N E D
C L~_ ( S
DATE
St. Croix County Zoning Office
P. 0. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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C-E?AR f OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS l / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION:tv SECTION: TOWNSHIP LOTNO.:BLK-NO.: SUBDIVISIONNAME:
1/ t- 1/4 / /T29N/R ni (or W
COUNTY: OWNER'S BUYER'S N ME: MAILING ADDRESS`.
Sf ~ , r~ c d sow n '
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: ICOMME-R-CIAL DES RIPTI: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
Residence ❑ New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
as au ❑s cuT-as au []S ou ❑s [ku
If Percolation Tests are NOT requir DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: AIX Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER D61A~ ELEVATION OBSERVED EST. HI HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
7,0
B-,2 -70" sc ff -7 -Z A" eols
B-,3 je,0" 9R, ?9' > 4::
h,' s
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I!Tle f~ AFTER SWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD 3 PER INCH
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 97,39
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he 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
"nistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
rint): TESTS WERE COMPLETED ON:
7-1
/ CERTIFICATION NUMBER: PHONE NUMBER (optional)
CST SIGN URE: /
and one copy to Local Authority, Property Owner and Soil Tester.
OVER
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