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Form - ST C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER El) ()x"QSOAI TOWNSHIP W a R lie L' i(I SEC. ~ T 2IN-R/,~F W
ADDRESS. ' ST. CROIX COUNTY, WISCONSIN
S 5---'16 -Z -3
SUBDIVISION LOT LOT SIZE ~D ff
PLAN VIEW
Distances and dimensions to meet requirements of ILH,R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a
i
f
t
rINDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
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 10 Side,0 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
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, 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, O Ft.
'
Number of feet from well:
v
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:
f17 Inspector
Dated: Plumber on job: ~d/- L-
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
L'AI!OR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS Cv/ DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
XXCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If a-fined)
NAME OF PERMIT HOLDER: Z
ADDRESS OF PERMIT HOLDER.
INSPECTION DATE:
Gaylen Enerso"n R. R. 1, Roberts, WI 7f
BENCI#M.gRKlPermanent reference Point) DESCRIBE IF DIFFERENT FgOM PLAN v J
N2 of the NW-,, Section 29, T29N-R18W, Town of Warren REF. PT. ELEV. D$r REF Pr ELEV
Name of Plumber.
MP/MPRSW N,, County Sanitary Permit Number.
Dale Moe 5813 St. Croix
69606
EPTICTAIVK/HOLDING TANK:
MANUFACTURER
LIQUID CAPAC IT TANK INLET ELE V.. TANI~OUTLL~~T ELEV WARNING LABEL
D D Q~ `V / `u PROVIDED: LOCKING COVER
l v ,/yJ j PryOVIDE D.
BEDDI G: ENTDIA.: VEN7MATL. HIGH WATER DYES ❑NO DYES ❑NO
K ALARM. NUMBER OF ROAD: PROPERTY WELL. 8 DI VENT TO FR ESH
AYES ONO y FEET FROM D~ t LIN/1/7 LET
DYES ONO NEAREST QO
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL
PUMP; SIPHON MANUFACTURER WARNING LABEL
LOCKING COVER
DYES ❑NO PROVIDED: PROVIDED:
GALLONS PER CYCLE: PUMP AND CONTROL sOPERATIONAL DYES ❑NO DYES ONO
(DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL suILOING I VENT TO FRESH
PUMP ON AND OFF) FEET FROM LINE AIR R INLET
SOIL ABSORPTION SYSTEM. Check the soil moisture atthe❑de Eh of lowing ❑NO NEAREST LENGTH or excavation. (If soil can be rolled into a wire, construction shall cease unt=FORCE DInME
rEH MATERIL AND MARKING
the soil is dry enough to continue.) CONVENTIONAL SYSTEM:
WIDTH LENGTH NO. OF
BED/TRENCH DISTq PIPe sPAayG CovER nPITs
DIMENSIONS rRE ,yjES / M AL: INSIDE DIA
LIQUID
oC 7 ~ PIT DEPTH
:
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR PIPE DISTR. PIP MATERIAL. NO H
BE LOW PIPES / ABOV6.C~VER Ej6V LET ELE END [y / MBER OF PROPERTY WELLBU LDING VENT TO FRESH
°l~/ PI FEET FROM 'LINE 4-
AIR INLET
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-
DYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER rexruRE
PERMANENT MARKERS OBSERVATION WE L: S
DEPTH OVER TRENCH' BED DEPTH OVER TRENCH BED DYES ❑NO DYES ❑NO
CENTER EDGES. DEPTH OF TOPSOIL SODDED SEEDED
MULCHED
D
PRESSURIZED DISTRIBUTION SYSTEM: DYES ❑NO YES ❑NO DYES ❑NO
BED/TRENCH WIDTH. LENGTH. IN 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 MATERIAL & 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.
COMMENTS: DYES ❑NO DYES ❑NO
PERMANENT MARKERS
OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINEYES ❑ NO E:
DYES ❑NO NEAREST
Sketch System on
Reverse Side. Retain in county file for audit.
GNAT RE nrLE
DI LHR SBD 6710 (R. 01 /82)
wiscons" APPLICATION FOR SANITARY PERMIT
~ DILHR y
(PLB 67) ~ COUNTY
DEGRRTTT1Er1T pF UNIFORM SANITARY PERMIT #
- In0USTRV,LRB0RSHUMRn RELRTj S
-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 A PRESS
J
PROPER' TY LOCATION CITY:
IV 1/,. r(/ /4, S 2 , Tom, N, R E (or) W owN OF: t~JU rr~~l
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
&A NA 6 Cf- f/ rc A
TYPE OF BUILDING OR USE SERVED 0c105? -167j'!457 [~6
Z 1 or 2 Family Number of Bedrooms. ~ Public (Specify):
THIS PERMIT IS FOR A:
Lk-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 Ik Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity )210 O L~
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):
2 U 0 Joint ❑ Public
d O ~2Private
I, the undersigned, hereby assume responsibl ity for installation of the private sewage system shown on the attached plans.
Name of uSignature: MP/MPRSW No.: Phone Number:
X-91- 6'. lqo 'e- 111I F,
Plumber's Address: Name of Designer:
2 4% 6--e~ l v ~~ax I
rL. e r
-COUNTY/ DEPARTMENT USE ONLY
Signatur of Issuing Agen Fee: Date: ❑ Disapproved
S~S ❑ Owner Given Initial
/Q .Z ~il ~C .l -~¢f -
J Approve 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.
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOF & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX-7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI_ BUREAU OF PLUMBING
C-NtONVENTIONAL ❑ALTERNATIVE Slate PI-I,D. Number
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If a-gn,,d)
NAME OF PERMIT HOLDER:
ADDRESS OF PERMIT HOLDER:
INSPECTION DATE.
Gaylen J. Enerson R. R. 1, Roberts, WI 54023,
BENCH MARK IPI«n.- L reference point) DESCRIBE IF DIFFERENT FROM PLAN.
RT. ELEV.: C T F. PT. ELE
NZ of the NW4 of Section 29, T29N-R18W, Town of Warren
Na-- of Plumber
MP/MPRSW Nn.. Cuur,ty. ary Perm'
Dale E. Moe 5813 Warren er.
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED-.
BEDDING. VENT DIA.: VENT MATL. HIGH WATER DYES ❑NO DYES ❑NO
ALARM NUMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH
D FEET FROM LINE LAIR INLET
DYES ❑NO
YES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL
PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
DYES ❑NO PROVIDED PROVIDED
GALLONS PER CYCLE: DYES ❑NO DYES ❑NO
PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRE
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMFTER MATERIAL AND MARKING,
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH. LENGT" NO. OF DISTR. PIPE SPACING. COVER
TRENCHES MATERIAL' INSIDE CIA -PITS LIQUID
DIMENSIONS PIT DEPTH.
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR
BELOW PIPES ABOVE COVER. ELEV. INLET ELEV. END NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
PIPES FEET FROM , LINE. AIR INLET
MOUND SYSTEM: NEAREST--►
Mound site plowed perpendicular to slope
uope: rpl Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
DYES NO meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER TEXTURE
PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVER TRENCH' BED DEPTH OVER TRENCH; BED DYES ❑NO DYES ❑NO
CENTER EDGES. DEPTH OF TOPSOIL SODDED SEEDED
MULCHED
❑ DY
PRESSURIZED DISTRIBUTION SYSTEM: DYES ❑NO D YES NO ES ❑NO
BED/TRENCH WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES: FILL DEPTH ABOVE COVER.
DIMEASIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTHIBU TION PIPE MATERIAL & MARKING
ELEVA ION AND EI EV ELEV CIA ELEV. PIPES oln
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY
COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: PERMANENTMARKERS~YES ❑NO DYES ❑NO
OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on
Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE'.
DILHR SBD 6710 (R. 01/82)
E,== Wisconsin APPLICATION FOR SANITARY PERMIT
DILHR ,~lCrd"x COUNTY
mEnTOF (PLB 67)
InOU5TRV,LR90R6HUMRnRELRTIOnS UNIFORM SANITARY PERMIT #
~ /
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
~ 3
fiV ~
PROP Y LOCATION'
1/ {(/1/4, S , TL/ N, R (or) W TOWN OF: c.J,,k r r e n
LOT NUMBER BLOCK NUMBER SUBDIVIS O~jN NAME ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
111/ A . z / 1 r) - ~J r • ✓ e. '
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. 41 ❑ Public (Specify):
THIS PERMIT IS FOR A:
Ta 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 L1 Vault Privy ED Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity ~`S c)
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): PR POSED (Square Feet): WATER SUPPLY:
,77 ~a zoo
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: MP/MPRSW No.: Ph~yN ber :
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ TAdV.r isapproved fil L~ wner Given Initial
Approved seDetermination
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
t
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 per( srwar:, feet required by code and the numh-r of
square feet to be installF
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). r$
15. The permit issuing agent may require a cross section drawing of the effluent disposal system. l !)p(
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/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 ~e•~ .J,
Location of Property A /VIJ Section T v~`/ N - R W
Township 1i,1~111 . Z
Mailing Address
jar C.~,rs C
Subdivision Name
Lot Number
Previous Owner of Property ~ ,
r~
Total Size of Parcel Cz_t
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yee
No
Volume and Page Number 'z 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 t i.6y that at.E e.ta tementa on .this 6oAm aAe tAue to the but o6 my (oun )
hnowtedge; that I (we) am (cute) the owneA(4) o6 the pAopenty daCki.bed in .thiA
in6o4mati•on 6o4m, by viAtue o6 a waAAanty deed AeeoA ed in the 066ice o6 the
County RegiAteA o6 Deede a6 Document No. 3 9la j'-l ; and that I (we)
p4e6 entty own the pnopod ed 6 to bon .the b ewage pod a ys.tem (oA I (we) have
obtained an eabemen.t, to Aun with the above deden,i,bed pAopeA.ty, 6o4 the
Bonet Auction o6 eai.d d yd.tem, and the came has been duty teco4ded in the 066ice
o6 the County RegizteA o6 Deede, ad Document No.
Ley
GNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
`DATE SIGNED
DATE SIGNED
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
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OWNER/BUYER u e -r A'V el-
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP
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PROPERTY LOCATION: /V Section c ! T N, R _W,
Town of ✓/rL 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
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I/WE, the undersigned, have read the above requirements and agree U)
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ~u
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.
SIGN E ?
DATE 45-
Croix County Zoning Office
St.
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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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'YNDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS:" 115 P.O. BOX 7969
HUMAN RELATIONS r•~' MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION TOWNSHIP/*61N+Eh TV: T N O.. BDIV ON NAME:
1/ N/R E (or).W
COUNTY: 9 E-R-'''3i'BUYER'S NAME: MAILING ADDRESS:
JE~
USE DATES OBSERVATIONS MADE
N0. BEUFIMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence NNew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN GROUNDPRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
Qs❑u SI_1 s❑u El sou asEu
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: {
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-l S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH tN. ELEVATION OBSERVED EST. HIGHEST TO_BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
z) 7-
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B- 7~, •J 17 ~N T'
B- S
B- "J 331'.3
Fin ~ S j Z Z~~~r j Y, $h ;?I'd S; 0' 3 ' 1 > 1
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER;;WELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- -7
P- C6
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. -C r;1UC i
SYSTEM ELEVATION J n6.3' ~4D 96, 1 '
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7 S~_' N F 7 w ee CAti p -1>AJ/ > E1 A L'1 ~"ZA✓E
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
7-7 \4 I S- tl -1
CST SIGNATYRE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER
Not, WOUSTS W if 60TAIND N16 OW:
legal
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INDUST MENT OF REPORT ON SOIL BORINGS AND SAFETY "'DIVISION
INDUSTRY, P.O. BOX 7969
LABOR •lriY D,'. PERCOLATION TESTS (115) MADISON, WI 53707
HUMAIN'iiELATIONS (H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOINNSHIPiMVffdlC FLAt+T\ : LOT NO.' BLK. NO.: SUBDIVISION NAME:
NE-U\ J/ zs /TZ9N/R E (o W w►~~z - -
COUNTY' . 9/BUYER'S NAME: MAILING ADDRESS:
!NIT eZX C'P' LEN 5t'~' 1v
DATES OBSERVATIONS MADE
USE NO. PROFILE DESCRIPTIONS PER OLATIONTESTS:
BEDRMS.: COMMERCIAL DESCRIPTION
Residence 1N New Replace I ca- ~_8Cr/ 8- 3' - c~y
RATING: S= Site suitable for sy=stem U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PoSSURE:SYL~EM-INFFILLHOOLDINGTANKTECOMMENDEDSYSTEM: (optional)' / JG
S ❑U SS ❑U• I[L. S UU SS ZU ❑SS NU II Z `1 RQJC"H~ - cf GciI S x / ~o L&
f DESIGN RATE: If an ortion of the tested area is in the
If tercolatin oTests are NOT required y p uns.H63.09(5)(b), indicate: N• A• Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
NU TOTAL DEPTH TO GROUNDWATER-ff*€S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
BORING
MBER DEPTH , W E L EVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
i ~.Z' ' tio>J~ mar@ a.8'brz_&/ ilTs; YBnS1
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B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TIT DROP IN WATER LEVEL-INCHES RATE MINUTES
i NUMBER INCHES AFTER SWELLING INTN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
Z
1 P_ P- 3
P-V8
P_ I 7 ) l 7 S~ STg] f .
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. TCZ~?UCN # 1) 6 y'
CO
O 96.8' 0 96 I '
SYSTEM ELEVATION
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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.
TESTS WERE COMPLETED ON'
NAME ( rint):
CERTIFICATION NUMBER: PHONE NUMBER (optional)
ADDRESS ~ -7 yZS-o/6y
s
Q27 y B\) x 7,,Z 6 L ~Sw oz w► 0 S~ I S -
CST SIGNAT RE:
,d DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
OVER
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ST. CROIX COUNTY
r } F WISCONSIN
j ZONING OFFICE
796-2239 (HAMMOND)
- j 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
July 12, 1985
Dale E. Moe
R. R. 2
Roberts, WI 54023
Dear Dale:
After speaking with you earlier this week, and then rechecking the
information on the corrected percolation test on the Gaylen Enerson
property, I did misinform you as to the need for a new sanitary permit.
Since the system location is being changed, new permits must be issued,
and the original one rescinded. Please stop at the office at your
earliest convenience to do so. The state does request the original permit
be returned to them, so please bring that (464867) with you.
Should you have any further questions regarding this subject, please
feel free to contact this office.
Sincerely,
4~-~ e "'eaj'A),
Harold C. Barber
Zoning Administrator
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ST. CROIX COUNTY AFA
WISCONSIN
,i^ = 1 F 7, u A d
s ZONING OFFICE
N.. r41 v 3 ipaA,,
796-2239 (HAMMOND)
1 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
July 19, 1985
State of Wisconsin, DILHR
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Attn: Carolyn Haag
Dear Carolyn:
Permit#64867, issued on 5-1-85 to Gaylen Enerson has been rescinded,
due to the location of the system being changed. Permit#69606 has
been issued for the system.
Attached please find permit#64867.
Should you have any questions regarding this subject, please feel
free to contact this office.
Sincerely,
Gc.
Mary J. Jenkins, Secretary
St. Croix County Zoning Office
Attachment: permit#64867
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, ~ E t ; E RER, WEBERS ASSOCIATES, Inc. BOX 74
421 N. MAIN STREET
t any' SF,-:eying Civil Engineering RIVER FALLS, VrrI 54022
Percolation Tests
(715) 425-0164
(715) 425-0165
ATTN: DATE f> - Z!-
1 Nti c_t~ rev CC:
r -
A E ENCLOSING THE FOLLOWING ITEMS:
NO. OF
COPIES ( DESCRIPTION
SENT TO YOU FOR THE FOLLOWING REASONS:
❑ FOR APPROVAL ❑ APPROVED AS SUBMITTED ❑ INFORMATION DESIRED
FOR YOUR USE ❑ APPROVED AS NOTED ❑ RETURN COPIES
{ NOT APPROVED ❑ FOR REVIEW AND COMMENT F] L,G RER, 'vv BER AND ASSOCIATES, ING
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