HomeMy WebLinkAbout036-2005-20-000
o cn o 0 ,r O o cn o g v 0= c O L1
O r.
3
(D (D m (D CD 'o A
v CD CD m ` 1
CD 3 CD 3
3 A:
Cn - I 2 T z O v T z 2 N z o T z 2 o z o T cn j o t O
0 0 0 (v N 0 Cn m o m N a co o m N o m W °C •
CL 0 0. 0
N CL N z n@ N O CD
n° N (b CD n N N CO 3 NO `^l
3 - 3 O O W O (D W m CD W 7 v O C !
cn
N Q O CU N D 3 (v N D 3 N D 0)
C:) 0- (D m Nj
0 C) :3 CD O(D CD CD
Cn C Q CD d CD C) a O O
°o
CL o 0-
0
N CD 7 N 0 3 N CA O C !i
N c - N a OV N c v
C y
o ) N N CD Q 0 i C/ . 77
o N a Q W (a o (D
N a a 0
W m co
CD m
° n o o o (i a o o a
N CD CD CD O CD
a- ~2 -2 M.
N O0o W N O 8 Ca (D OZ Ca -4 -4 Cl) Ca N n r, c
Cn cn z z z O•
CD CD CD i
Z77 ;p 'U fl: AI •
° 0 0 0 3 O O O s O O O s ry~~i
o -i -I 3 0 0 3 0 v 3 1 O + 4
3 y cn cn o g 3 cn cn cn 0 3 cn en cn 0
O ~0 O O n 17
a w v 0v q n N m v w g c
=5 (D (n 6 w CL
m m_ m m_ m - CD
•N~
N D' OJ ? 7 3 d A :5. 3 D) A N
:3 CD C,
CL a)
-4 -4
N
z W z z co z z co z
D Q o D m o D m o
co _O O n O n
Cn E CD Cn c h
CD CD N O (D ~y
CD CD
-O N -O •
N Q ~ -O ~S
co CD 0 CD 0
cm
.0 Cc Cc a Cc aD
CD CND C CD C CD
w n co v m (v
n 3 m 3 3
z CD cQ CD v (D v s i Cn
p Z CD
c s
O a A z 0
v C O
O
W _0 j
CD ((D W C CDD W 0 a a z
0 3 0 30 3
y 3 3 r: m
D N CD N CD
A
W m p A F
C
CD
D
D 3 ~o D •o O N D
O _S CL CD N 7 0- CD O CD CL
O N_ :3. x (D d C 7 O a
co N O A G CD
E Q
N o m 7 Q 0 m a n n m c
CD o a (iCD z ce o a o CD o 4
° a CD N x
O N N
v CD 0 N 3 N
7
o x
O
N CD Q~
° CL y
~ n S J N
CD O _T x t
* CD O ~ v
W x O CD O CY
O (m
x CD
W S S CD
N (n
m fi
CD CD 4
(D x, m SU N
S
O
d O COD 0-
m 3 CD N
fl 7 CD O
a
O O O b Cy
O O :D :D
(D
D'Q ~n
O O
'Ge O
C) (D
O n p Q. OO Cl
ti
Wisconsin Department of Health and Social ;,ervi0ex
Plb. #67 3/70. Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
L/
A. OWNER OF PROPERTY
Neese Address (Street, City Zip C de)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTEA'DED COUNTY
_ Check Ones
CITY VILLAGE LEGAL DESCRIPTION T3//U
Li
j~ TOWNSHIP
C
C. IS LOCAL PERPIIT REQUIRED FOR THIS WORK? V YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALSs Prefab Concrete G~ Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: j
E. TYPE OF OCCUPANCY
Cheek Ones One or Two Family Residence /I Commercial Industrial Other
Specify
Number of Persona to be Accommodated IS/ Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES : NO
Other (Specify)
G. MASTLR PLUPSBER MAKING IN ?TATION
Nam
e: 42z L"i L JE9i3- cK/ Address: ~r Z~)~-V/Lioense Numbers
HP C
Signature of Applicant: C L MP RSW 5
' T I
Address: C~L~ z H. (To be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date) Permit Number
Agent (Name) y ! - For s L- iii ~1
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid, Agents will forward application, the fee of $1,00 for each septic tanK and the third copy
of the permit (canary) co the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED 4-w --71 ACCEPTED BY RETURNED
(Initials) 30 0 (Date) See Cores.)
FEE RECEIVED VALID. No. PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(.Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R Y P 0 R T O N S O I L P I R C 0 L A T I 0 N T E S T z,
A 7
N D S O I L B O R I N G S r
TO
DIVISION OF HEALTH - PLUMBING SECTI6N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P S R C 0 L A T I 0 N T T S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
lst Wetted Overnight in Minutes last Period Last Period Period Oner Inch
Example
P - 0 36" To Soil 10" Cla 2£" 25 Yes or No 30 1 2 112 112 60
RECORD DATA FROM MIN II1UM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 36" Below reposed Abso tion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
L- a sple
B - 0 72" 72" Black To Soil 12" C1 18111 Sand 18". Gravel 24"
;L0 14, -
rt~~l
RECORD DATA FROM MINIMUM 3 BOR9 HOLES
PE OF OCCUPANCY: -.2•
RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons
FOOD WASTE GR L`IDERs Yea No Dishwasher: Yes No Automatic Clothes Washer: Ye No -
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPI.ACII4ENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length _4*1'e Width J Z Depth 3 Tile Size ~ No. Lines 1-)
Seepage Pits Inside ffi.eiaeter f~4 Liquid Depth 5
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the cedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that thCA ta recorded an loo ion of test holed are correct to the best of my knowledge and belief.
NAME 'v r--5 ^ TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS ~~L 1
DATE SIGNATURE
f
Wisconsin Department of Health and Social Services
' Plb.^#b7 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK ~\x
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Code)
V j (O
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY Check One:
CITY VILLAGE LEGAL DESCRIPTION I
7tj
TOWNSHIP /4/2-
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? 1 YES V NO PERMIT NUMBER
T
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
-Check One: One or Two Family Residence ~ Commercial Industrial Other
Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES !X NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES= NO
Other (Specify)
G. MASTER PLUMBER MAKING ICI CATION
Name: Cal Address
vv~~ ya License Number:
MP
Signature of Applicant MP RSW S
Address
i
H. (To be Completed by Issuing Agent)
Date of Application Pee Paid =~`J
Permit Issued (dat.) Permit Number
Agent (Name) For: Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.OU for each septic tanK and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED - -~1 ACCEPTED BY RETURNED
FEE RECEIVED (Initials) (Date) See Corres.)
VALID. No. PERMIT NO. t1~
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
r
SEPTIC TANK PERMIT NO. Az -'i;
R E P O R T O N S O I L P Z R C 0 L A T I 0 N T Y S T
AND SOIL BORINGS
TO
DIVISION OF HEALTH - PLUMBING SECTI6N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches Kinutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
lst Wetted Ovornicftt in Minutes Last Period Last Period Period One, Inch
Example
P - 0 3611 To Soil 1011 Cla 2611 25 Yes or No 30 1 2 I L2 1/2 60
~ >a I I J C)
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 3611 Below Pro osed Abso tion S stem
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inohes
Example
B - 0 7211 7211 Black To Soil 1211C1 1811 Sand 1811, Gravel 2411
t, ~y
7 -2-
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
i
PE OF OCCUPANCYs
RESIDENCE: Number of Bedrooms` OTHERS (Specify) Number of Persons 'el
D WASTE GRINDERS Yes No y Dishwasher: Tea NfoAutomatic Clothes Washers Yes ~ No
EFFLUENT DISPOSAL SYSTEM: NEW V EXTENSION ADDITION REPLACEMENT I
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length 6) Width Depth >-el Tile Size y No. Lines
Seepage Pits Inside Diameter- Liquid Depth_
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and locatio r test holes are correct to the best of my knowledge and belief,
NAME TITLE
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS %eU
DATE _7' SIGNATURE
f
C) n to O K v n
d
z z
O N N rye d f on 3 cD ~ 1
b CD v at e
:Z$ (D D) CD
\ 1
Fl- n N O
M >y o
rt
o
i a H o D o w N o Ln E - - w C
O t7 CD CD N Oj c N O
N C (ZD W j 7 J C) C
H 'd ~ H o CL O Cn D O N 1
Z H oo n= (D Z3 O
I CD o
W Cn m o
H n
(D 3 N W O O
L7 O
m ~ ~ 0 D CD tea.
d rt. CD c~ N Cn
a
-0 W
CL
CD c
r••r•~ 0 a = ~ ~ cfl
N I L O CD
CO Q
O ~ co co < N p C
I \O o oo Co ty
oo I Ul Ul Z Q Nr
tn O o w f
h- v v V p °1 !~I •
Z cn Z OOOo ry~~r
I t~ o
Fl- 0 E 3
Ol °g 3 N a
CZ - m m h
ry
:E: o.
A D O a d !~i
C7 rt
Ft P3
(D (D
rr r m D
o rt H• m m
O CA a N
c" o
O p N
n a ~ N
W Z
cf)
zo~z
v C
v o
rn
-CDO N
l
c CD N
1 CD
CL 3 ~
Z CD -1 (n
N O ? Z CD
c ;u
Z
CL
Q_
C/) w
co _0
CD
I I - Z
0 3 a X
O ! (n J
3 m
`1T N ~
0 A
---1 D
C.J E
CD
CD
a CD
CD
o
Z) -n
o z a
o
CD
n ~
~ N
d
S
`V
I
fi
ti
b
N
O
O
a
A
0 b
:3 Z)
• "ZI
A a
A
o O ti
a
o
CZ) a-
Parcel 036-2005-20-000 07/18/2006 05:32 PM
• PAGE 1 OF 1
Alt. Parcel 31.31.17.651 036 - TOWN OF STANTON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - FLANUM, ARVID & RAMONA
ARVID & RAMONA FLANUM
1808 OAK RIDGE DR
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 1807 OAK RIDGE DR
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 0.450 Plat: 2238-OAK RIDGE ESTATES
LOT 31 OAK RIDGE ESTATES Block/Condo Bldg: LOT 31
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
31-31 N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/27/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.450 20,000 133,500 153,500 NO
Totals for 2006:
General Property 0.450 20,000 133,500 153,500
Woodland 0.000 0 0
Totals for 2005:
General Property 0.450 20,000 133,500 153,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
RIM' Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~Z riltd
TOWNSHIP : a i- SEC. T zjLN-R_~W
ADDRESS f ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
v ~ tv
r
R
I
4 e
IL
I~v
IN ICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used N=«% /n
T
Elevation of vertical reference point: 1 / c"l Proposed slope at site: / j
SEPTIC TANK: Manufacturer: -11 ,c, Liquid Capacity: /d ?
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, O feet
:From nearest-property line Front,O Side,O Rear, O feet
Number of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
1
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: ~ 5 Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, a Rear,0 Ft
Number of feet from well: 7e-l
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:
License Number: r S C
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
MADISC-N, WI 53707
kjCONVENTIONAL EALTERNATIVE sate Planlo Number
• (It ass i9nedl
❑ Holding Tank E In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. rDRESS OF PERMIT HOLDER'. INSPECTION DATE.
Arvid Flanum . R. 2, New Richmond, WI 54017 _ /-,,70-~-5 1-'So
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT ELEV.. CST REF. PT. ELEV.
SW SE Section 31, T31N-R17W, Town of Stanton - Oak Ridge, Lot#31
N,-', of Plumber, j"PWPRSV1 No Cou,ty Sar„r:~;y Permit N~rn ber.
Cal Powers 1563 St. Croix 75001
SEPTIC TANK/HOLDING TANK: _
MANUFACTURER LIQUID CAPACITY f'11 INLET FI.FV TANK OUTLET ELEV WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
DYES ENO EYES ENO
BEDDING. VENT DIA.. VENT MATI HI(;HWATER ER~OF ROAD. PROPERTY WELL BUILDING VENT TO FRESH
ALARM LINE AIR INLET
T FOM
DYES ENO DYE ❑fd EARES_T_ _
IN
DOSING CHAMBER: _
OCKING COVER
MANUFACTURER BEDDING IL IQUID CAPACI TY PUMP Mt)DI t t't P ti10 !ON ^.'A'J01 At; T I I,2E H WARNING LABEL JPROVIDED
PROVIDED.
EYES ENO EYES ENDYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS .1E PAT IONAL NUMBER OF I'HOPEHTY WELL BUILDINI, VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LIN AIR INLET
PUMP ON AND OFF) EYES ENO NEAREST-~
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I,IAMF TE H MATE HIAL 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:
WIDTH LEND 7H NO OF OISIH PIPE .F rf;l^~:, (:,'VF~2 E DIA ZFI 17 LIQUID
BED/TRENCH TRENCHES .InTFHln1 PIT DEPTH
DIMENSIONS 3 ~Z>
GRAVEL DEPTH FILL DEPTH OlSlli PIPF UISTH PIPE DISTR-PIPE MATERIAL NO l7ICTR NUMBER OF PHOPERTV WELL BUILDING VENT TO FRESH
EFI OW PIPES ABOVE COVER EI E V INI f I ELEV END PIE' LINE AIR INLET
FEET FROM
C f J- -NEAREST - -
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
mel ets the criteria for medium sand. TIONS MEASURED.
DYES ENO
SOIL COVER TEXTURE tRNtn1JINI%-I'llW, 111111111VATION111tLLS
T`_JYES ENO EYES NO
DEPTH OVER TRENCH BED DEPTH OVFH THE WAI BF 1) JTI! OF TOPSOIL Ill SFE Di 1) MULCHED
CENTER EDGES
L EYES NO DYES ENO DYES ENO
PRESSURIZED DISTRIBUTION SYSTEM: _
WIDTH LENGTH NOOF LATERAL SPACING HAVEL DEPTH BE I OW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL NO t11STH DISTR. PIPE DISTHIBUT ION PIPE MATERIAL & MARKING
ELEV- ELEV DIA ELEV. PIPES DIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING, OHILLEDCOHHF(.TIY COVER MATERIAL PLANSCAL LIFT CORRESPONDS TO APPROVED
DYES ENO ! YES ENO
COMMENTS: PERMANENT MARKERS. IORS ERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM LR IN_
DYES ENO DYES LINO NEAREST
'N .
Sketch System on Retain in county file for audit.
Reverse Side.
DILHR SBD 6710 (R. 01/82) SIGNATURE
77~~~~
E Wisconsin APPLICATION FOR SANITARY PERMIT 61-
D I L H R R COUNTY
(PLB 67)
OEPRRTTEnT OF UNIFORM SANITARY PERMIT #
In DUSTRV, LRBOR 6 HUMAn 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 MAIL G ADDRESS I r
PROP TY LOCATIIA GIB:
VILLAGE:
1/4 " 1/4. S N, R : Y (or ' TOWN oF: ~h..
LOT NUMBER BLOCK NUMBER SUBDIVISION N ME NEAREST ROAD,-LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED aG-
1 or 2 Family Number of Bedrooms. ❑ Public (Specify): +
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
D4 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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
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 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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of t e ivate sewage system shown on the attached plans.
Name-pf P (umber (Pgr)t): SignafL MP/MPRSW No.: Phone Number:
Plumber' Addr ss: Name of Designer:,/
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
1'6 j
r
/ ) I ❑ Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
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 iia
Location of Property ~,)s 14, Section , T~ N-R~L W
Township
Mailing Address's
-T
Address of Site
r y
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 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
1 (We) ceAtiby that aPt statement6 on this bonm ane hue to the best ob my (ouh)
k.nowtedge; that I (we) am (cute) the owneA(b ) ob the pnopenty daCAibed in tW
inbo,tmation bosun, by viAtue ob a watvcanty deed tecotded in the Obbice ob the
County Regi6teA o4 Deeds ass Document No. ; and that 1 (We) p~tu entty
own the phoposed .site bon the sewage disposat system (ot I (we) have obtained an
easement, to nun with the above deg i.bed pnopehty, bon the eo"tlcuction ob 6a.id
,system, and the same has been duty ne.conded in the Obb.iee ob the County Reg-usta ob
Deeda as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
' H
• a
ST C- 105 r
r
a
ti
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
OWNER/BUYER ~Ake",,
ROUTE/BOX NUMBER ; Fire Number
CITY/STATE ZIP
'f
PROPERTY LOCATION: 14, ~4, 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. H
0
E
I/WE, the undersigned, have read the above requirements and agree czn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ro
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 /
DATE
St. Croix County Zoning Office
P.O. Box 98.
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
' v
r ~
x m
x d
c 1D vi a> CD c c N 3 O
p 7
~v (D CCD Co = fD <
`CD
rc H 0 Q 3 = W W
O C O ~ W
to ~D' Z 7• ~ (p `C = 3 C ' ' N ~ `G ~ IA
of CO N to c~D Q CD N O O
g m O O p K<
m a 0 n W p (D cD
n fD 7r lD a W Co
CD
\ cc) A 3 ~D (D 1 S- P
d Z ;Sr
-t (D fD TO
~r
O CD _ C (O tp W
O W O
S co
0 1 92
3 l< C- C:
z (M 13:
cS-3 r as
O c
W ° N O =Q (D 7
O (D W A 'C 0 n
(<D (D C c tp Q _A
v O
p .O. 0 = W n n 0
C
c --X 'a CL
CD 0
D^. CD(p O O aQ• O W O
fn N O 5,7 0
cn Z' ch
v C a
C v w =
m
0 (D m cD n O lD z
mm~ 3 EncvCD 2~
wa D 0 -
--i
CD o E; 0
CL m
CL CL :3
w w ac°~(CODf
v 3CD° 0CD C m
(D m y m ti n~
w=3 =vw
a~
< CD
O N n 0
v3a
CL 0 N cQpcf°'
S- c
3cu m vm W
CL ~ m
~ aa~ a c v,
* O cn o
v °
c ~c co w S CD
6.y o ° c m cD 3 N 0
CL OA O d ° 0 N° ' C
CL C o a) S D C fD
° CL w 0
A~sA; CL C3 0~m00 0 w a a N O O
° _CL
(D cc) o < 3
o 0
\ O
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AWD PERCOLATION TESTS (115) MADISOP.O. BOX N, WI 79069
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION:.. SECTION: TOWNSHIP/MUNICIPALITY: 11_0~1\10.:JBLK.NO.:SUBDIVISIONNAME:
N/R ;
COUNTY:. OWN)ER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BED,RMS.: COMMERFIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
QResidence ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system lam' /j ~~/1,
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LJHOLDING TANK: RECOMMENDED^SYSTE optional)
s ou os ❑u Qs ❑u ❑s ou as ou
If Percolation Tests are NOT required- DESIGN RATE: If any portion of the tested area is in the
r
under s.H63.09(5)(b), indicate: if Floodplain, indicate Floodplain elevation:
L~'4
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH FIJI, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
_ r
~ r
B'
B'
B'
PERCOLATION TESTS
- f.
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 1-I*1GHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 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 ercent
of land slope.
SYSTEM ELEVATION -
- -
1
!
-
I,
,
~s T N
i
, i
I
t
J
i
t mss` a _ P T-
J '
It
_
I
I F --I---- -7 I t
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 (pTESTS WERE COMPLETED ON:
t
ADDRES,iS: f 1 CERTI (CATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
1
To be a co,tE7 iv* and Hccw, i ~ro
2, ? rrso say . C,-'€ ;not cow l inputs .m deer this , FIw : nc M coarrm ,dad p;a`£ p
Si d F t umber of hedr p ms or C !nvn¢ -.o € e
, is s o .'>f t.1t bra a rpi f12{a "it y's.z_,
5. i>eo€pa(akie d wrabilkv Mi ,{2 boxes , A i _ ; SC. r FABLE R)H Y> 1101 1) 7 ALL
(-°='-Fi-i ,I t,,, I ARE RtIULEEDI ,iU B\S'E.) p. €s x.'42_,
s% PLEASE use t4'3€\ M.h,p ..i ,mot p? shown ?o for p:ip .c.€tarl Ix o„ rj t?4 tr€ 6 p.
7. Dti#AK A l IBi- i,atj .r acc m v +„€rr; t, yon t° ;t locatu"n s, L ti ,
3, Ma strr££ a PFi" t:ac p.E.Pi??;"rfY x, _1 o d , v A "=•`r'.g . ,r.£en , joint ate clearly la i , and aic Cpet,1.anni q
tp-I. 1, "he ,€'it_ .r o~tion w 1i a MA p£p o tp.YEpion) d cs not ma~% ,£l twti Nl A rr th apt.,opriat hox;
11, ,_1€a the _ on TO Ise' V tW cu m r.pAr wK er LY i7 tita H Y<. ,rrl'a.P3a;
Make ortihin r,..€€-, and € =akum, as 1...I£=!!; L a\4..1.,. '"aOU ITS TS Md.JSC l?E . t-[t,_._'r TIiH TlJ''
AE3BREVIA71,10% FOR CERTIFIED SOIL TESTERS
BR bahvk
q Wwwr 3" LS
r
i-s g Jz P.=£„? Wvf R£.r€ F-.r t, 3 ;
rnecl, Fat e
a
~3 ,
10 Smutty LomE Less 11w
S a rn , , O t
p
Coy l.£,im. y 7 rrrn",,
p p(,t It .3p,Yp - rY ~..ieo t£r a 1 R?r,
Sanoy s -W
r o Cmy tr, ;ai
°s =p, Many,
t' stint .
Kith h~o-l
`rec Mii.i
"c "I r is the foil unp in tt € inn , a or the s ~ptt mayroq1v St~
1,
rr sr€ t:, . e .d tia 0 pvnw, r5p;E,}. .,e't : 1 .J,f'€ for f
i,= „ tSa ,P , ncirv"o he Y E r'= c. r On tt.r-Ep a We a€.i€`aip <',i ht 0 e,5nr v
!-"K
I
r. ~ .
I I
Jell
f
1
s
E OF
PA
C) c) y
Fresh Air Inlets And ODcervatlon Pipe
r- Approved Vent Cap
Minimum 12" ADave
Flnol Grode
2U- 42° Above Pipe -4° Cost Iron
To Final Grade Vent Pipe
Donn Noy Or Synlheilc Covering
sttn 2° Aggregate
Over Pipe
UlstriDullon
0 0 0 0 0 -Tee -
Plpe
s
Beneath eaach Pipe
B - o Perforated Pipe Betor
Be _
o Coupling Terminating At
Bottom Of system
ice=
s of I `q r~, ~I -
SOIL FILL
r•
DISTRIBUTIOVI PIPE
APPROVED S4WTHETiC COVER
OF STRAW
° -MATERIAL, Dr
2 OF AGGREGATE OR MARSU HA'~
a~OF% P A.;GREGAT E
ELEV. OF- FEET
DIS" RIq'JTIJ1) PIPE To 6E AT LEAST 2 IIUCHES BELOW ORIGIUAL GRADE
Ak)L, AT LEAS_1 ZO IIUCHE_'~ BUT 1.10 MORE THAU H2 IIUCHES BELOW FINAL GP_ADE
MAXIMUM DEPr11 OF EXCAVATI(DO FROM ORIGINAL 6KAK WILL BL 1, INCHES
MINIMUM ®EPrtt OF EACAVATVDlJ FKOlt'.. 1*61WAL 6R49f_ WILL 'M_ INCHES
SIGIUED:-C~t~2'
LIC EIU SE AJUMBE R:
DATE
110