HomeMy WebLinkAbout040-1177-95-000
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AS BUILT SANI'(_ARY SYSTEM w-jowr
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~i!• ~ ~~~-4^c3, of c?Y" TOWNSHIP ~.~~y_...._
v OWNER ► 1
n GGL~ ST. CROTX COUNTY, WISCONSIN
ADDAZSS
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j hd LOT LOT 5I !,E
SUBDIVISION ' X Cap -
PLAN VIEW
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Diet>~►»ees atld dissensions to meet requirements of 63
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WI7 FFF:I?'(' OF SYSTEM
EVERYTHING '1FI;N 100
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'1CNt'~~Q Describe eDescribe tt►e vertical reference point used
Proposed slope at site: ze, _
of `VSrt cad reference point .
Liquid C.apac.iTy: MT,ANXt SanufAcI urer
1
of r~,rige u&►edt Tan manhole c~ov~~r el.c.vr~tlo►~~ :
'
'~A1c t'41et Elevation: Tank Outlet Elevation:
fect
0 2
r~.',ll~tlElb Q•f feet' from nearest Road: Fxont / Side,Q Rear,
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line
} 1 qb ? feet from: W81~ _ » huildi.n};: zta . _ _
,F 4Jq,
infomation of the above w; S4,11t
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Sire
Elevation of inlet: Bottom of tatik elevation:
Pump off switch elevation: Gallon:; per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, Side, O Rear, Q Ft•
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Trench:
Bed:
Width: ( Len$th:Number of Lines; Area Built
Fill depth--to top of pipe:
Number of feet from nearest property line: Front, O Side, (~7\ Rear,O Vt
Number of fe.e.t from well.: _ . - _ _.....1_. _ .
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 boxQ or distribution box0been 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, QRear, OFt._
Number of feet from well:
Number of feet from building: _A~_ _ - -
Number of feet from nearest road:
Alarm Manufacturer:
Inspector
Dated: Plumber on job
License Number: /yp'e S_kv ,I ?3~ -
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Parcel 040-1177-95-000 07/17/2006 03:40 PM
PAGE 1 OF 1
Alt. Parcel 13/24.28.20.697 040 - TOWN OF TROY
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
KENT D BANNER O - BANNER, KENT D
PO BOX 765
S ST PAUL MN 55075
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 259 COVE LA
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 7.700 Plat: 2491-ST CROIX COVE 2ND & 3RD
SECS 13 & 24 T28N R20W LOT 40 ST CROIX Block/Condo Bldg: LOT 40
COVE SUB # 3
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
Notes: Parcel History:
Date Doc # Vol/Page Type
02/03/2005 786635 2743/115 TI
07/23/1997 1145/522 WD
07/23/1997 1077/29 LC
07/23/1997 873/337
more...
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 7.700 127,000 329,900 456,900 NO
Totals for 2006:
General Property 7.700 127,000 329,900 456,900
Woodland 0.000 0 0
Totals for 2005:
General Property 7.700 127,000 329,900 456,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 133
Specials:
User Special Code Category Amount
III
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
III
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS
DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
XXXXONVENTIONAL ❑ALTERNATIVE StatePIanl.D.Numbe,
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (if assigned)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER
INSPECTION DATE:
Richard D. Holper 1879 Cove Lane, Hudson, WI_J - /G
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
REF. PT. ELEV. CST REF. PL ELE V..
SE NW, Section 24,T28N-R20W, Town of Troy, Lot#40,St.Croix Cove IIIAdd
Na- of Plumber.
MP/MPRSW No. County. Sanitary Perroa Number'.
Paul Cudd 2739 St. Croix 64861
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUjN PACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
VENT DIA.. VENT MATL. JHIG1111 TER 7• ❑YES ❑NO ❑YES ❑NO
BEDDING'. NU ER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH
ALARM. LINE'.
❑YES ❑NO T C AIR INLET
❑YES O NEA REST ~✓v
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIOUID CAPACITY PUMP MODEL. PUMP,SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
YES ❑NO ❑YES ❑NO ❑YES FIND
GALLONS PER CYCLE: PUMP AND CON TROLS OPERATI ONAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE I AIR INLET'
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing
IL[ N(;rH JDIAMETER MArFRnL 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 NSIUE DIA tPITS LIQUID
n TRENCHES. MAT'L~FiIq L; PIT DEPTH'.
DIMENSIONS V
GRAVEL DEPTH FILL DE TH DISTH. PIPE ~JUILSETVHR PIPE DISTR. PIPE MATERIALNODBFLOwr;IPES ABQVECOVER ELEVNLFi . END NUMBER OF
? PIPES LROE ERTV WELL BUILDING VENT TO FRESH
3 /o/•c~ 8 , 2 S• FEET NEAREST ROM / _0 s0 G8 AIR INLET
7 --s
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-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DEPTH ovER TRENCH BED DEPTH OVER TRENCH BED ❑YES ❑NO ❑YES ❑NO
CENTER DEPTH OF TOPSOIL SODDED SEEDED MULCHED
EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH. LENGTH. NO. OF LATERAL SPACING. GRAVEL tBE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MA NIFOLD DISTRPIPE MANIFOLD MISTRPIPE DISTRIBUTION PIPE MATERIAL %MARKING
ELEVATION AND ELEV.. ELEV.. DIA.ELEVIARBTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY CVERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERSOBSERVATION WEUMBER OF PROPERTY WELLEET FROM uNE
❑YES ❑NO ❑YEEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNA TITLE///G/%/~
DILHR SBD 6710 (R. 01/82)
wlsconsln W1 APPLICATION FOR SANITARY PERMIT
~ DILHR St. Croix co
(PLB 67) UNTY
DEPRRTTT1EnT OF
- InDUSTRY.LABOR &HUMRnRELRTII7n5 UNIFORM SANITARY PERMIT #
5%P & /
-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
Richard D. Hol er 1879 Cove Lane, Hudson, WI 54016
PROPERTY LOCATION
SE 1/4 NW 1/4, S 24 , T 28 N, R 20X)q:giq W TOWN =X: Troy
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK SPLAN I.D. NUMBER
40 St. Croix Cove 3rd Cove Lane
TYPE OF BUILDING OR USE SERVED
Ek 1 or 2 Family Number of Bedrooms. 3 ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Re air
L 't Replacement Soil Absorption System ip
Revision ❑ privy i
❑ Alternate System ❑ Reconnection
❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
IN 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 #
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions, issued
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
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
Class 2 1260 1260
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility r insta ation of the private sewage system shown on the attached plans.
Name of Plumber (Print): ignat
Paul R • Cudd MP/MPRSW No.: Phone Number:
P (715) 425-2049
Plumber's Address: Name of Desiggnneer:
9 r:
Rt. 5, Box 364, River Falls, WI 54022 Arthur Wegerer (576)
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee:
Date:
❑ Disapproved
1 a G~;Z` r
a 4 ~ lz6G(- //-r c~ ❑ Owner Given Initial
Reason for Disapproval: ~
Approved 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.
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/contractgr,("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property Section , T N - R W
Township \ (mac b-~ - l
Mailing Address
- \~v~Jw.
Subdivision Name
Lot Number O
Previous Owner of Property 2 S ~Pc2~e
Total Size of Parcel Z c~
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
.
Is this property being developed for resale
(spec house) ? Yes /C No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
C, 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) eenti.6y that att s.tatemente on this 6oAm cute .tAue to the but o6 my (oun)
knowP.e.dge; that 1 (we) am (ane) the owneAW o6 the phopen.ty d"cxibed in .thin
.in6onmati,on 6oAm, by vi tue o6 a wahnanty deed neconded in the 066.ice o6 the
County Reg.iA ten o6 Deeds ab Document No. ; and that I (we)
pnee en tty own the pn.opos ed e.i to bon the sewage pod 6 ys-tem (on 1 (we) have
obtained an easement, to n.un with the above duc i.bed pnopehty, bon the
con-6tAucti.on o6 said system, and the dame has been duty neeotded in the 066.tee
o6 the County Regiz teA o6 Deeds, as Document No. )
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) -
~-(7 Zu-4 S- V -,)-o
DATE SIGNED DATE SIGNED
• H
V)
' H
a
ST C- 105 rr-
a
ti
SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County z
d
a
OWNER/BUYER ~~~L.42o O \~~1 peg
ROUTE/BOX NUMBER 1 as \Z`1 Fire Number
CITY/ STATE \A,~ Za W ~ zip ko
PROPERTY LOCATION:, 4, Section T N, R W,
I
Town of -Tt-aA St. Croix County,
Subdivision `T Cr' C°Ue~~b3 Lot number o)
I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
E
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- 10
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 V~-
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.
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NDUSTnJGENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUMAN RELATIONS
N, WI 53707
(H63.090) & Chapter 145.045)
ELOCA TION: SECTIO N: TOWNSHIP UNICIPALITY OT NO.: BLK. NO.: SUBDIVISION NAME:
Ntu~/a 1/a N/R ~~E or'W NTY: WNER'S DYER'S NAME: MAIL-FgG ADDR'TSS:
_~)~X.1
USE
DATES OBSERVATIONS MADE
NO. BEDRMS.: JCOMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑ New 17'~•Replace
3 N. 35 1~1.
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-G
RO1ND PR ESSURE:SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM: (optional)
1~IS DU ~S ❑U ZS ❑U DS ®U ❑S.1 u u
If Percolation Tests are NOT required DESIGN RATE: If an
y portion of the tested area is in the
under s.H63.09(5)(b), indicate: 7> Floodplain, indicate Floodplain elevation: N h.
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-I CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH f~B OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B a
o. v h'n n~Q9` C') B3 yr c s
,Z) B TS i Z. L/ ' 8n Js 1. k~h lye a i
.I7 Bh CS
B- t~VcT8),'S T-s W.13n S
~ ~ 8n i148t S 1, 1 ' ~'n cS J
B-
o,~ ~3n ~ o• '7 ' Ian csr 5
B-
B- 1..~...,,1
PERCOLATION TESTS b-j
TEST DEPTH WATER IN HOLE TEST TIME DROP 11\1 WATER LEVEL-INCHES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERT I E HE !
P- /y
P_
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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 y3
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I, the undersigned, hereby cbrtify 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 WERE COMPLETED ON:
ADDRESS:
C CERTIFICATION NUMBER: ^P~HONE NUMBER (optional):
Vim. I - 4c7 L~ LL.-"~~~'-, ~ .i i .:3 I L/
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
a_'~.tt=;
t and
taS <t: trust tl€r,r
fq',A lt'A3Ui=_ nornber of "ei COM it'rcial ,t`r- paiiftFiT
b r i k_lm"s t., t„w ;.t =t asNS:
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11
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vc~ tica1 le~f.,,'LCS i, iGlt„i', li„ EaC;:,€t are ,..,-st:l p' and ave p t., arw9 ;
1`a(Yf f',e= i~c ,„uand
Lstrf,, 1o rx e ~.oV's fah t€r "LlI S, plai, d,; a, {?k;Y"cola-tion'LQSL ex<ii''f-
i f „ .4gr, - i ff e r p't?,. 7€., ,iE, f7r e. ,':j jsa r i,?a , _ a <pr ,4;t}'r9f,
(3 - 0" SS sand",
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CROSS SFCTID)J OF A BED S~STFM
ItJ ~t1 C, Az) E
SOIL FILL I Z' OF AGGREGATE
DISTR)BLITIOEI PIPF~
-APPROVED SYLITHETIC
IA/,TFRIAL OR 9" OF ST RA
C ( ( OR I',ARSH HAy
c (e'OF2 AGGR1: GAT£
t- L. E V. o f F E E T
PERFoFZA-Tl - P~
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DISTRIbU-1 10U PIPE TU BE AT LFPST - 7a-> 11JCHE5 BELOI---~ OP,IGIIJAL GRADE
AIJD AT L A,57 -D 1)!CHCS BUT iJD MORE THAU `i2 IuCNLS B= I-DW F1UAL GRADE
I
MAXIMLINt DEPTH DF 1_XCAVATIO).; FROM ORIGIQAL GRADE %-JILL BE _53
)►JCHES
/"Mlt UM DEPTH OF EXCAVATIOU FROM ORIGII,]AL GRADE WILL BC IMCHES
SIcr
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H63.05 PLOT PLT-N
_'how: '
LA Location of building served CN] Dosing char ;,r
[A Septic tank Vertical/rlorizor.tal reference x>ir;t
Building sewer System elevati or, is 5
Effluent system Well
Replacement system area Prop=rty lines w/in 50' of sysi m
f Di strihutlon boxes Scale = _ I3 , or di Inensi c,~r•d
, , anC COn'=rnl
''fr. & iioi~el No. - 31 _ ft Size Force ?fair'
T. D. H. Jr, i P'. SL. JCIe
Place C"-ieck Inark in appropriate ox, oI: r1of D ai? r;1Cw:
y
y p ~S7.C k1' 11\.3 J+~ ti~i~v~i STS
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LLB T -a
o i TO
By the granting or approving of the above plan, or upon the event of a subsequent
permit being issued, St. Croix County and the St.C.ro xCounty Zoning Administrator, does
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
a'F~ r . nstalla , n.
Ire
Dame
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