HomeMy WebLinkAbout030-2014-70-000
0 O , 0
C~
.d+ ~ C O
1
7 ? C) 3
~ CD CD ~j CD
M M C rr.
I O
0 o o o ° a o cn rn °w `C
° ° =r is °
CD it d (D O O N
CD t? O O N N p~ N O h
I~? m y m m ti ~ -o co ~ O
N N O S j rY `
v O
3 Ci C1 O O
N N C_ =3
N A 7 O
iv (n D a o, ~1.
CD G CD N O. ,A
_0 a N W co
3 0) -4 lot
CD O C\7 00 :E
z n r N
C In S ~Cl Z t+t} ° 20 cO a; 13 O U
N (O m
Z O O O
w o c n c `ice
I < z
o w e N o P° cn c i N° o D
I- `n y ~p K O ,'fDy `D y A t~
I'D TJ o m I cn
a' X U)
Ul CD 3 0)
Z t>
(D rQ N) (D C~
L-4 :D
F'3 m a- ` z
z N
z co z
z C 0 D a m
v O
•
H ° m CD m "fti
ON (n
t' I m iv ~
t~7 In ti c COD CD
d 00 v fi w m °
Ln
_ CD
I z C° cn -I cn
N y y Z O = O A Z n
W 1 Q W m N C .a
I a' O n A z 0
S Z V~ v a O
l o.
co M m w rn
CD (D zt
o o
x k-4 o Q C
a
QN
I w
~ D
o r.
3 m c
:3 °z °
0
m
O CD N N
C1
A
I ~
I ' S
i yA
N
O
a
A
0 b H
O
O O ~ ~
y~
O 0- y
ti
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP 1 SEC. ,a T N-R r W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of II,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
i
-At
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: ~,.1 Liquid Capacity: J
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,o Rear, 0 feet
From nearest property line Front,0 Side,0 Rear, f 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/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: Number of Lines: Area Built:
Fill depth to top of pipe: y1
Number of feet from nearest property line: Front, O Side, O Rear,O Ft. Il'
G ry !
Number of feet from well:
r
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: Plumber on job: ~yr
+f C; `
License Number:
3/84:mj
DEPARTMEN-t OF INDUSTRY. INSPECTION REPORT FOR
LABbR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 5`3707 BUREAU OF PLUMBING
41CONVENTIONAL ❑ALTERNATIVE State Plan LO Number
L1 Holding Tank ❑ In-Grr-und Pressure ❑ Mound T'assP l
',AME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER.
Jean Schwartzbauer 509 6th St. N., H NsPEQTIO"QATE
udson, WI
`NCH MARK (Permanent reference Point) DESCRIBE IF DIFFERENT FROM PLAN.
NE SW, Section 36, T30N-R19W, Town of St. Joseph, Lot # 1 (REF PT. ELE V. G$T REF PT ELEV
~Narnc of Plurn ber. -
MP/MPRSSW No. County.
Richard Hopkins 1059 St . Croix San tars Permit Number I
54942-T J
SEPTIC TANK/HOLDING TANK: I
MANUFACTURER
r1 , LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED.
~ ry PROVIDED:
BEDDING: VENT DIA.: VENT MAIL. HIGH WATER v v aL t YES ❑ NO ❑ ~;.rZ^ O
aA~N
/ . NUMBER OF ROAD. PROPERTY WELL. BUILDING. E TO FRESH
ALARM ❑YES O- I FEET FROM ~J LI" q 11 AIR INLET
❑ YES ❑ NO NEAREST -
DOSING ` J I
DOSING C AMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL_ PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMP AN DCONTROLS OPERAnoNAL ❑YES ❑NO ❑YES ❑NO
1(DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL BuILOwQ IvENTroFRESH
PUMP ON AND OFF) FEET FROM LINE AIR INLET
❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check thesoil moisture at thedepth of plowing LrwcTH ID IAMETER 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 I
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO. OF
BED/TRENCH DISTR RIPE SPACING M COVER - NSIDE CIA aPlrs LIQUID
DIMENSIONS TRENCHES / r n A,RIAL:
DEPTH
1
GRAVEL DEPTH FILL DEPTH DISTR PI F DISTR. PIPE DISTR. PIPE MATERIAL: NO. D TR
BELOW PIPES ABOVE COVER ELEV IN F T ELEV END NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
PIP J FEET FROM LINE AIR INLET:
I _ NEAREST-s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM i
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑ YES meets the criteria for medium sand. TIONS MEASURED.
❑NO
LISOI=LCOVER TEXTURE
PERMANENT MARKERS OBSERVATION WELLS
I
DEPTH OVERrRENCHBED EEPTHOVERTRENCH'BED ❑YES ❑NO ❑YES ❑NO
CENTH EDGES. DEPTH OF TOPSOIL SODDED SEEDED
IMLILCHED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIALS, 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.
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENTMARKERS: OBSERVATION WELLS:
NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
U4
Sketch System on
Reverse Side. Retain in county file for audit.
SIGNATURE. - TITLE
DILHR SBD 6710 M. 01/82)
wlsronsln APPLICATION FOR SANITARY PERMIT
• ® ' L H R COUNTY
.i
(PLB 67)
OEPRRTTEnT OF
UmgnRELRTIOns UNIFORM SANITARY PERMIT #
- IiIOUSTR V,LR90g6 H
v ya
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
_
PROPERTY LOCATION CITY:
N 1/4_'_'J 1/4, S 3 VILLAGE: , - ,
~ • T331N, R 19 E (or) Wt rowN OF:. LOT NUMBER BLOCK NUMBER SDAME NEAREST ROAD, LAKE OR LANDMARK T TATE PLAN I.D. NUMBER
Iliq e
TYPE OF BUILDING OR USE SERVED 7D-z,2J6
`2" 1 or 2 Family Number of Bedrooms. Public (Specify):
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.
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 Con rete Constructed Steel Fiberglass Plastic
Septic Tank Capacity 4 Q
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: n
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):
1
" 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): Signature: J~WIMPRSVVV No.: Phone Number:
Plumber's Address W Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
~7 ❑ Disapproved
Y ~/J j'4 ❑ Owner Given Initial
2 2~ < 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.
. , SAN I A Y PEER I E CCU:.-Y
u) 21LI EH TRANSFER/RLENEWAL UNIFORM PERMIT - r
(PLB 67-T) - 7~
~PERMIT'RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
IPROPERTY LOCATION: CITY:
VILLAGE:
,S T N,R E (or) W TOWN oFF
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: (NEAREST ROAD, LAKE OR LANDMARK:
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
I
k I, the unaersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
proDerty.
~'LU~ R'S SIGNATUJPE: PREVIOUS PLUMBER'S NAME (IF CHANGED'):
-_U~:'~_ .~C
r i
i?n_
r
1 C)
W 01 W'a
Copy O VV (ler
:BD 2P9 1r- 5i Cogy - Plumber
L
, O N
m
ti c
^'f~~ r*town~
c (O w p m ~CD~
N CD a (p n A (D O
co y O 0 W W W
O C O w
:3 X,
o ~iC p C ~ (D '0 a (D (D - p A q
=3 CD (n
to ° a 0 n A) p =w (CD O (D
_n w~ O CDCD a0 ~ i_
w m m
=3 CD CD
CD +
(D -w O (D P
O
r
0 3 Q o o 0 0 m w
j t0
O w O
O
w L C c EL
7 W C.<Q. j *
CD
w:
_O, C N_ 0 w w
O W N - (0 0 CD :3
a N
O ~7 m w 1~CO 'Cl '0 >
, m C D n
< O Q
(D (o Q O
(D C cn
m(n~ Oyc_ (D1
O = O n 1= FV n n_ p
M 0 w B. ~ am ° O
(D (o Q' : w
m N N m-, w N C N
a N m m m (O N? a
cD° 3 D
~
CD O r. N (o > D
(n C
was ~w r0 o m
L7 (n CD =r a m N (p w
S a
3 C0 cn(nwwm~ C m
c a
01 mc~ °a°m°_~
{ N (D 0 . (D (n
00.0 CD -
0 cno0=c(CD D ~
0
~Q c ..c •CD w m (D " t0 A N in
Q O cC c C Caw o' m
w w~ (D
va) ° Q= F a?
c <co w =r cD N
ao oco a o N.m 0 M o c
a Caw c~-~mcm m
rpseo~ ~a3 o?mo°3
w a (D ° o 3
~Or co m
0 0 z
0
1
W
C c ct " c C,
(NJ 5
~r C 3 E ~a c
0 0 o~> n of TO c Q
O7 o m vaa 2> a 0
m E M N
(l7 v) m ~ cQ u c d E E
c E o O-_ > o
o
~ c c
F- -m Ed"' o m `m
Cl l Q p 2 Y c a c
d y
z o o - ~c Q "
>.2 c
" o
Z ~u E Na° -m dY to W
r
U Ea Ca o Ow m v mo E i..
N Cam > E_ E E ' wt `mr
a O
> o r t c o
0
7EE M 'n TO C
H c ® WM
. L6 C " 3 m'. 3 c' C c o W
EcmM o~ d C~ -
E(' O
cc CO o~ C`E Cc
W a E
o a-M d =d
■ y y m W W > d 3C > O t o W
Q a a E EL d c c m U a.z
■ V aC mC $~~c cE Cd ' NC oC LLJ W
` . L N r t c r C = o a Q
c 4, 4, 0
. U 7 Of 0 C V
'C C C CC E
=.a d w U y O ` j m O a~ w t a
Z \w z z
~O
■ C)
o ~ q z
0 0 L oC)
U
LJ6A Z z ~ D.
- L
U) Q U)
\ o Q z
CLM ~ w 00
r) -1 1 jln
z o v
U Q = O
Z
A.
LLJ
Ila
6 U)
h~
y U)
w COO*
w O o r w
co w co z w
C36m cl
CD 0 C)
a o
- C90D O CL Q a:
I
-
„ r
C L 6 "'7 ~ P LCST A H) S F T I ICI
_ PR0`)ECT L U M R
L0CAT10N L IC, ENJ SEf/=
P L l [\/I A P
J' Beclro4tly~
W
fa'
t mod',
, 0A
ISO • G S
Sao'
I j-
TK,5M
FRESH hII: TPIX'I'S AND OBSERVA`r-10H PTUE
C'i,0 S SECTION
Approved Vent- Cap
Minimum 12" AI)ove
Final C;
I
I
CclS1- Iron
Above Pipe'-.J Vcr,l- 11-i.pe
To Final Grader
Marsh Iiay Or Synthetic Cover i n(j
Min. 2" Ayyreyil
Over Pipe---
D:i.stri.1-1)uI:i_on Tee
Pipe
Aggregate Perfora I-ed Pipe Below
r I3enrr a Lh Pipe ---C01j1,1 i_ng Termi.natAng At
Bo t l-om of System
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUUAN RELATIONS SAFETY & BUILDINGS
P.O. ROx 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI' 5370' BUREAU OF PLUMBING
(CONVENTIONAL ❑ALTERNATIVE state Pla LD. Number
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound nr a s,9neul
NAME OF PERMIT HOLDER:
ADDRESS OF PERMIT HOLDER:
INSPECTION DATE.
a Schw. zbaueA 509 6th St. N. Hadson., wI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
REP PT ELEV CST REF PT ELEv
N>= SW, Section. 36, T30N-R 19W, Town o6 St. Joz eph, Lot #1
Name of Plurn ber.
MP/MPRSW No.. County Sanitary Permit Number.
RobeAt Utbticht 3307 St, ct(.o,(x 54942
SEPTIC TANK/HOLDING TANK:
MANUFACTUR ER.
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL
LOCKING COVER
PROVIDED. PROVIDED.
BEDDING. VENT DIA.: VENTMATL.. HIGH WATER ❑YES ❑NO ❑YES ❑NO
q HM. NUMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH
❑YES ❑NO FEET FROM LINE LAIR wLEr
❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL
PUMP/SIPHON MANUF ACT UREH. WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED PROVIDED
GALLONS PER CYCLE: ❑YES ❑NO ❑YES ❑NO
PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN LINE
PUMP ON AND OFF) FEET FROM I AIR INLET
❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ENC;rH
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE DIAMETER MATERIAL AND MARKING
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF DISTR. PIPE SPACING COVER
TRENCHES INSIDE DIA =PITS LIOUID
DIMENSIONS MATERIAL' PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTH
BELOW PIPES ABOVE COVER ELEV. INLFT ELEV END PIPES
. I NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
FEET FROM uNE AIR wLEr
NEAREST--►
MOUND SYSTEM:
Mound site plowed perpendicular to slope
and furrows thrown
upslope: rp 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 ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER rexruRE
PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVEHrHENCHBED DEPTH OVERTHENCHBED
❑YES ❑NO ❑YES ❑NO
CENTER EDGES. DEPTH OF TOPSOIL SODDED SEEDED MULCHED
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
FILL DEPTH ABOVE COVER.
BED/TRENCH WIDTH HELEV FED LATERAL EHAL SPACING GRAVEL DEPTH BELOW PIPE
DIMENSIONS
MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DIS rRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV ELEV PIPES DIA
DISTRIBUI ION
NFORMATION HOLE slzE CTLv
COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: PERMANENT MARKERS EYES ❑NO [:]YES ❑NO
OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
❑YES ❑ NO FEET FROM LINE'
❑YES ❑NO NEAREST
Sketch System on
Reverse Side. Retain in county fife for audit.
SIGNATURE. TITLE:
DILHR SBD 6710 (R. 01/82)
wisconsin APPLICATION FOR SANITARY PERMIT
'COUNTY
(PLB 67)
~ D,EPgRTT
T.EnT OF UNIFORM SANITARY PERMIT #
InOUSTRY,LRS P&"umAn RELRTIOnS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
sc AU/,f A4 2 dj_ po
P'ROPERTY LOCATION 'CTT-V': _
vt1/450 1/4,S 36 ,T3~N, R E (or W Tow o 5~ - LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, RK STATE PLAN I.D. NUMBER
es /1-1 3 N/
TYPE OF BUILDING OR USE SERVED ~j
1 or 2 Family Number of Bedrooms. / ❑ Public (Specify):
THIS PERMIT IS FOR A:
Y New System ❑ Tank Replacement ❑ Repair
Ell Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System L~ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
K 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: evC o") C"e f~c~ I H O.v 1 S
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 (Sq are Feet):
z J yy ~Q x 3 ~3 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of PI iha Signature: i1ftP/MPRSW No.: Phone Number:
30'NEIL RD., HUDSON; WIS. 330171 s )3d rt~L I
PlumbeOI111111119.k(WWR PLUMBER LIG. NO, 331, Name of Designer:
MINN. INSTALLER & DESIGNER
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
b( ❑ Owner Given Initial
~S 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/contractgv,("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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I
Owner of Property Jean M. Schwartzbauer
Location of Property NE ~4 SW Section 36 T 30 N - R 9 W
Township St. Jgseph
Mailing Address 509 6th Street North
Hudson, Wisconsin 54016
Subdivision Name
Lot Number 1
Previous Owner of Property John Leys
Total Size of Parcel 3.21 acres
Date Parcel was Created 9-25-81
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes X No
Volume 4 and Page Number 1114 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE 17OLLOWING:
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) eeAti 6y that a.PC statements on this 6onm atce hue to the best o6 my (ouh )
knowledge; What 1 (we) am (a4e~) the own0L (s I o6 the pnope&ty dac/Li.bed in thi/s
in6oamation ;6onm, by vi,vtue o~ a wwL,ran.ty deed neeofcded in the 066ice og the
County RegisteA o6 Deeds as Document No. ' g rf 3 and that 1 (we)
pnesentty oun the phoposed site ~m the sewage &apdpoolsaX-system (on 1 (we) have
obtained an easement, to n.un u:ith the above dese,%bed pnopenty, (ok the
con,sti uctcox o~ sa,~d system, oral the sane fias been duty aecoAded in the 066ice
o; the Coun,l y Regizte., o6 Deeds, a Doetunent No. ) .
SIGNATURE CF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
June 28, 1984
DATE SIGNED DATE SIGNED
r-,
• U,
• Y
S T C - 105
1;EPT LC TANK MA I NTL;IN ANCE A CNEI1-:NT
0
SC. CCUix CuuriLy
v
t1WiJ l: l: / It U L: I: Jean M. Schwartzbauer_
- -
ROUTE/ B O X N 111.115 1-:1, 509 6th Street -North F i FU N Limb c• r
C 1 •I' Y / ; 't ATE' Hudson ---Wisconsin 11 54016
1' I, l l l' I': ICT Y 1• L)
t; ,'1' 1 I) N: NE SW i~ n 1 30 N, h
36. _
owit u1 St. Joseph-_-__._- St. CI-uix County,
Suhdiv Ls iuu LoL dumber 1
i
Imi)vo1) 1- 1! k_1 and MI ilttunaut L 01 vuur j L i ysteIII r:uuld resuLL i11
iL:, prulllit t I I r U Iallit ru Lt) II:It1LlIU was LL' PIUpc•r maiIItCIIIIIt!t' c:uri -
ts o f 1) u111 1)iI1 unL the sL' 1)tiC Lank. evrry Lllree yCitrs ) r ullc'.r,
it uuudud, by :1 1 iCC 1 ;utl -;e1)L i_c tank 1)uiupt•i WhaL you iiut into
l.hu y:;Lem CLI11 11 1 ec'L Lhe I IIIIC 1011 t)1 1 lit. c-k pt is La1tk a:; a LrL'aIC
meuL ,iLap•e Iii Ltlu wu Lc d.i:;i)u a1 sysLciii.
`;t. Cruix Cuuuty CLt SideIILS in.aY bU uLtl',ihIL, L0 1cc 1VL' a t2,raitL I r
it III it xlIlk uut o1 bO ul LI I c C0) jt. 0f rep.laCiill et:L of it Jall iillt, sv -i L eill
which was in 01)urILiu11 priul- to JL11y 1 , 1 8. SL i;ruix County
act.ep[.ed L I I i S I, I-o Cit lit iit All It St. k lL)8 with Chu I-Ctjtlirtulit c11L L I A L
uwlturti t,l ;ILI now r;yStclit I I-LAc to keep t_I~~ it y:it~nls 1)FU1) crly
III it i. I I L a in e d.
T I I U prit pcrt.y clwnur trr~ Lt. I litI L Lu ~t ( 10i County 11 11 I
t'urtil LCIL iA1) lurid, snud 1) y the owner tII by a Ina_itCr it 11111hcr,
joIt rit eyIli it rl 1)lLi lit bt•r, resLri led plit tit hur )r i I icCILSL:d 1)ulit i)CI vuri-
fyiIIl, t haL (L) Llie U11-;>i Le wA t(2 waLltr disi)t)saL sy:;ten1 is in 1)ru1)cr
(1 l)uraL 11c' 11di L Lou and ( 2) al is:r in,i)c t-L iL>u atld It Ill iI1 uuc -
essary), C It u sc1) L i c tank: is loss th.it 1/3 tul.l of s-1udZ;u and Scum.
Curt i f i C a L iurl LurIll will be ~;uIIL ai)1)ruxiIlk Li tely 30 days 1)riur to
three year ux1)Lrat.ioii
0
1, /W1?, tale undursiL;nud, have. read tiie ahuvc requirements and agree
to maintain the private sewage di_sposaL system in accordance with
r-;
the Stanclit rdS set forth, herein, aS set_ by the Wisconsin Depart - .u
mcnt of NatLi raL ltusuurcus. Certiticatiuu lurid must be utit pleLed
and rctLi rii ud to Lhe St. Croix County X 11i_I1 0Lfi-ce witlli.I1 30 days
of the: tit ruu year ex1) i r a L i o I I t-latu
S 1 C N l? D-- ?~-(7
DATE' June 28, 1984
St t ruix County Zo[IIIt O1 1 ice
Is ox a
11 it 111111( ud, W1 54015
715-~96-22311 or 715-425-8363
Sign, date and return to above address.
KERMOTT AGENCY, INC. * =
OF riO~dES r
600 Third Street, Hudson, Wisconsin 54016 • 386-5151 • Twin City 435-5755
~ `sUiV 1 CFO
1983 bt
June 14, 1983
Mr. Thomas C. Nelson
St. Croix County Wisconsin
Zoning Office
Hammond, Wisconsin 54015
RE: Lot #1 of Certified Survey Map 373625
John Leys property
Dear Tom,
I am zvriting this letter to assure my buyer of the
above-noted property, that the filling cats take place.
From the base of the hill the buyer can fill an area
250 ft. by 250 ft.
Would you please sign this letter on the foll
line to SI1oSJ your 'approval?
Thomas C. Nelson
Also, I have enclosed an envolope for the return of
this letter. Thank you.
Cordially yours,
KEIRMOTT A"G~EN'CY, INC. GALLEERY Or nomES
DAVID F. ANDERSON
DFA/gw
Enc.
~"r `CO/5M7 SANITARY PERMIT
UD 1 L H R County,
~GROUNDWATER SURCHARGE
W=U5TP4LgBOR & murr %n1 F~LgTlp1'15
Sanitary Permit No.
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly known as the groundwater protection law. This change in statutes was the result of over
2 years of steady negotiation and public debate. The groundwater bill included the creation of
surcharges (fees) for a number of regulated practices which can effect groundwater. The
surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to
the groundwater through your soil absorption system or the disposal site used by your holding
tank pumper.
The monies collected through these surcharges are credited to the groundwater fund admire:
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwa a,, ,
it's worth protecting. A.,
I,
Ground $
Signs re of Issuing A ent: Groundwater Fes: Date: WisCO E!`S
buried
t~ttit~
LAMI 42,
.or
DILHR SBD-7289 (N. 05184)
u
c~1T,~3'_;
~ ~r~ r* , P. L. B .J is 1 l DJ
'%lAnELAS-10%S 1 G0 LA A N Tr::_ d MADISON, W1 53707
(N63.09(1) & Chapter 145.045)
iCAT:CN: S~( TION ` '04VNSHIPt'"}H+~tFbhf*IFt~Tt'4^" UT NO. 3l_< PJO.' SU3DiVIS O`1 tJAjAE: , _P I .:OUNTY: OJVNER' NANIE: tit A1LiNG ADDRESS:
r rn r-
v
USE
DATES OBSERVATIONS MADE
t~---y~Residence NO. BEDRMS: COMMERC AL DE CS RI?TION: ~~I / r __W_LL( DES_M PONS. 7i A N TESTS:
L !
~
t_._New ❑Replace r r ? , -
RATING: S- Site suitable for system U- Site unsuitable for system
U+ Ta t MOLT' : [71 IN G PJDfRESSURE: SYSTEMlN-FI~LLHOLOING TANK RECOMMENDED SYSTEM: (opti(inal)
! 1
r-
'ercoiation Tesrs afr i?T rwi;uirei!OE.`atr' ! Ft= i
pp it ,r; :oat,on of the sad ea is in the
s,Hi33.Og{5)jbl, . za, p Ll >c c,piain, indicate FIoodplain elevation:
PROFILE DESCRIPTIONS K07 - f= a GD~f4t-ir1rV r\ G'S. ~'7,ZR~~Pa+V0
- Vii )'r hl
RORI;'JGi TOTAL
1 T GR JUNOr1ATER INCHES CHARACI ER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
3crZIrJFsrCH i:a, O:J --i
t t0PTH 3SE I R n VrD EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV, ON LACK.)
l
C) /k 1 S1 :a r 41 _ L f w , 0 '-a
4_.0 U j of j w l4) r.! V/C U I nI j.i:-1Af
,
vv
p- r
I.oJ r L~ 1.~0 ~ J 1 tin l - _ i c. e•
t C1l ' _
tr j,~C ~ft j~-iOnl 7~. L C,4c~ tF~Gz~C,Y,IIr~ ~~tO,C v j;.rl_~rs
~~/qty PERCOLATION TESTS1•SO z.40 3N IU~~
t TEST r1EPTH l';';1TFR IN HOLE TEST TIME DROP IN t"J.ATER LEVEL-INCHES' RATE T:^.IPIUTLS
JU:BER~t r r'\~TEI?SV/cLLING INTERVAL-PAIN.
PcRt001 PcRIQD2 _ ___p R PER I`•iCH
P- ~ ..l .,z, 1
23
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.
(.,(O '(°'E, % -a T" P Z-' 0,+-t~ c_ E t~
S'(,STEM ELEVATION 75 Gam. ~ c,, A r tics - t~~
1W oll
1
t
'
7 I
41
xar i
i I( ff st t
r r
r-
w
.A, 4
40
I
I r i I\ I j ( r d
r
c, { t ,
AV~c.4 R~
s._ f_ j.T. , N
Ia3~nrcrl 1\-Aiel`•v__ - EL_ 100.00-- 7-0 F,nF Pro& Sfi6 ot2-~at 3fe
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 Wisconsin
•.dministrative Code, and that the data recorded and the location of the tests are correct to the best of my knoviledge and belief, 0 L, G Z fl 6l~
~:JAME (print : k'.A 1~ ~uq-J
4 TESTS WERE COMPLETED ON:
':DRESS: CERfI (CATION NUMBER: JPHONE NUMBER(optron, l):
{ L~
6, !U°
O -re t'"_. S`r- N CST S{GNA7URE:
tea +-a S 114 r="`D 'TJ4 R a v 0
k) r.1
01STRIBUTION! Or,gwn)i -rnrr nn? r•npy •n I rra, Acrth,)rity, Property Own-tr :md Soil Tester.
\l
crjOS5
SMrJON
~y -
i
x!'.53
~ w
lp
D ~51 La f l c / ~f af- -
1 ! d r
A. 3
2 Cr/(IG~L~ u+ r!~<;!TF_ SEPTiC Fl L',' ~lNs c;
"T. 3O'NUL RD.: HUQSON, WS.
ROBERT ULBRiCHT
'tilS. MASTER PUJM3~~ LIC. RO 3
T
1 Sfl 9 `
Fresh Air 9niett And Observti'r;r n Pipe
W Approved Vent Cap
Minimum 12" A-hove
Final Grade
_r
Above YPipe 4 Cost Iron
fJ~,y -fo Final Grade Vent Pipe
i5 Marsh Hay Or Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution ---Tee
Pipe . 0__ 0 .0 0 0
6) " Aggi,egate ® Perforated Pipe Below
Beneath Pipe 0 Coupling Terminating At
4 .a