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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~47/-f P"04s0~ TOWNSHIP #t)Pf0A) SEC. / T N-R W
C
ADDRESS 3~~ VA~A 4A'P ST. CROIX COUNTY, WISCONSIN
/I/U PSU't) s
SUBDIVISION LOT 2-1 LOT SIZE
s ~Tioti
T
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN iv2 FEET OF Si6iEM
v~/T• ~f ~rT,E
~OsT 4,
em v. - 160 - d J
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36
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F3 --~I
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1
INDICATE NORTH ARROW
%d~J MoS?- PaiNf ~
BENCHMARK: Describe the vertical reference point used rP. T jt FQ 0017--
Elevation of vertical reference point: 2(50 ' Q FT' Proposed slope at site: CJ 6
SEPTIC TANr.: Manufacturer: Liquid Capacity: 100
Number of rings used: Ad-1-2- Tank manhole cover elevation:
"
(7730
Tank Inlet Elevation:` S;a Tank Outlet Elevation: s' 62-
Number of feet from nearest Road: Front,O Side,0 Rear, O > feet
From nearest property line Front,0 Side, (9 Rear, 0 feet
Number of feet from: well, building: r ~T r
(Include this information of the above plot plan)( 2 reference dimensions to sept
SEF RFVEKSF S I M'
PUMP CHAMBER
Manufa urer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact r: Pump Size
Elevation of inlet: ttom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Ala Switch Type:
Number of fe from nearest property line: Front, 0 Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: x Trench:
Width. I
Length: S-2- Number of Lines: L Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, O 17t
Number of feet from well: _
Number of feet from building: 3
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid dept 't'. -eepage pit PIPS=,Lion:
Are uilt:
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: apacity:
Number of rings used: Elevation ottom of tank:
Elevation of inle
NumbE o eet 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 f
.
Dated:_ ~ P1umb&eron job:
License Number:
RPTI PLUMBING CO.
RT. 3 O'NEIL
RD., HUDSON, WIS. W16
ROBERT
WIS. MASTER PLUMBER LIC.INOi3307 M.P.R.S.
MINN. INSTALLER & DESIGNER LIC. NO. 00663
h3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
'P.O. BOX 7969 BUREAU OF PLUMBING
tMADISON, 1-V1 53707
UCONVENTIONAL ❑ALTERNATIVE sltfad55P9nn~IiD.N tuber
Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Shenm Petenzdn 311 Ga,2ahad Rd. N. Hudson W1 "'1 f-SIV ,l ,30
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF, PT. ELEV
(U NE,See. 16, T29N-R19W, Lot#21,NrJA_thL%ne Station, Town a6 Hudson
Na- of Plumber. MP/MPHW No.. County. Samtary Permit Number.
Rabett UtbAicht 3307 St. Ct oix 49447
I i I
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. ]TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING CO
100o ~3 5, G P OV DED. PRO M,~jED~
1n iWl r.Y ,VJ7 / L ES ❑NO L11''E'S NO
BEDDING: VENT DIA,. VENT MATL. JALA. IGH WATER NUMBER OF ROAD. PROPERTY WELL. [WILDING. JVENITOFRESH
'
M . FEET FROM LINE AIR INLET
❑YES ❑NO ❑YES ❑NO NEAREST ~~0~ S~ lG I
DOSING CHAMBER:
MANUFACTURER BEDDI NG. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MAN F CTURER WARNING LABEL LOCKING COVER
PROVIDED PROVIDED'.
❑YES ❑NO ❑YES ❑NO ❑YES FIND
GALLONS PER CYCLE; 7]7D CONTROLS OPERATIONAL,.- N EMBER OF PROPERTY WELL BUILDING (VENT TO FRESH
(DIFFERENCE BETWEEN F T FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑ O AR EST
IN.
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NGTlf JDIAMFTEH MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease ungi CE
the soil is dry enough to continue.) AIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE CIA. -PITS ILIOUID
BED/TRENCH / TRENCHES MAU~waAL PfT DEPTH
DIMENSIONS
GHAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. H NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END PIPE n LINE AIR NLET
.a I" _ - FEET
ESTO--► ~oZ-2 IDZ~ (j~ ~fZ~
2- ~ G- NEAR
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-
❑ meets the criteria for medium sand. TIONS MEASURED.
YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES f NO ❑YES ❑NO
DEPTH OVER TRENCH: BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL DDED SE ED MULCHED
CENTER JEDGES.
ES ❑N ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERA SP CING. GRAVE PTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD S PIPE MMATERIAL'. DISTR. ID ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
El EV. ELEV.'. CIA V.'. IPES DIA.:
ELEVATION AND .
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED C ECTLY JC E RIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
Z ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
6~
9d s~
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE "f..+' TITLE.
)I LHR SBD 6710 IR. 01 /821
wnconsln APPLICATION FOR SANITARY PERMIT
1' t D ILHR ~ ~ COUNTY
(PLB 67)
~~inouS T Y,LABO UNIFORM SANITARY PERMIT #
-.InOUSTRV,LRBOR6 HUTFin RELRTIOnS /V~
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/,x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING DRESS
-311 AeA r 41,> - X a rt igJ'a
PROPERTY LOCATION CITY
Sly) 1/4 Pf- 1/4, S T)~ N, R cr E (or) W TO OF : /~.~195e V
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
9 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.
YJ 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 Tf~
Holding Tank capacity Al~
Manufacturer: 7-S 0,10, Ze-) ~)Z 0 77
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):
52 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: A IWP/MPRSW No.: Phone Number:
Po 13" i ~ c,' I / S3'0 -5 )3j7 - / j
Plumber's Address:
~1 ~ Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
f ❑ Owner Given Initial
V A
- / rJ pproved 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.
hurw - S T C 100
Owner of Property 4//~l~•E'SC~~t✓
Location of Property IVC =y, Section T 2e14~N R i W
Township ~J, QSo ~t.J
Mailing Address 1
Subdivision Name A4, CT It Li., t= S74 T/0 'L: Lot Number
Previous Owner of Property ~_~/1~fF S
Total Size of Parcel ;7. O ; /.}C P C
Date Parcel Was Created Iq jN AuC-ie,( s r ile6,
Are all corners identifiable? Yes No
Include with this application one of the following:
X/ Certified Survey Map
.Deed
.Land Contract, or
.Othe~rt Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. r S ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an 0asement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. _
STUN TUNE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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1
DEPAFTI`4ENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOWAND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
t,y _ (H63.09(1) & Chapter 145.045)
LOCATION: SECTION TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME
'/4 '/4 /T N/R E (or) W
COUNTY: OWNER'S/BUYERS NAME: MAILING ADDRESS:
7 r
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 2 ✓ New ❑ Replace G
j,/ I
-1
RATING: S= Site suitable for system U= Site unsuitable for system r. > r/ ~'h ! ~ ,F'I~ C"AS ~,vg -
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK. RECOMMENDED SYSTEM: (optional)
❑s❑u ❑s❑u ZsEl u ❑s❑u ❑s❑u,
[under Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
!v PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IN ' T CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
i
B- 2'
3S
~n /3v,~, ,j2S' ~w.G 3,313v. /s, .5 i-V Cs
B- ,
j 77ca j(~ L! /off /~ti'• 3,v /s,
B- A
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IN ;rT-._ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ Z
P_ d 1a,. 1 n :.~f
/
P- 23 e-
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.,
SYSTEM ELEVATION
3 r ,
I
3
. . e
f
3' 71-1-1
i
E ` . T mm
for ~ con APpp
ventio
sep t.
ncIl
r -
I
YsteIll
E .
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): TTOMESTTE TESTING CO. TESTS WERE COMPLETED ON:
SATE APPROVED SITE EVALUATIONS PERC TESTS`
CERTIFICATION NUMBER: PHONE NUMBER (optional):
ADDRESS: MINNESOTA LICE".`- NO. 00663
WISCONSIN LICENSE NO. 55-02452
T. 3 O NEIL RD. HUDSON WI 54016 CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
a.
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REPORT ON SOIL 13ORIN&S ` PERCOLATION TESTS 115-
PLOT PLAM PR0-TEC T r. D. PA rE-
IIOMEESITE TESTING CO. 4-:r-
,,t~s..3, W NEIL ROAD BOB
r-1vUS0,41 WIS.- 54015 C57- SS- (~2 y~Z
PROPOSED HOUSE MUST' WE 2~ Fr p,e A'Ofr "0,4f iLL TEST ,g,PE~3S,
PRo POSED weu M V5T LIE .Sp Fr OR /'yDJQ£ FiQov~
/f LG TEST /i,PE~S ,
X = l~E~c ~oc~r~o of p~ = #A,vP gt19ERfD o t 54AaE1 13oRE5
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LEGEND o
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Fresh Air Inlets And Observation Pipe
SOIL TESTIINcj By
140Me":S1T;E TEST NG a-~'• - - Approved Vent Cap
"050N, WIS. 4=is- 116 Priinimurr 12" Above ~
! C .r/ i~_ ti 4 t ' ,
, h~ 1''
L-~
Final Grade t
yy'' Above Pipe _ 4 Cast Iron
Vent Pipe
-To Final Grade
p Marsh Nay Or Synthetic Covering
Min. 2" Aggregate
~ ~
fG6l 1 Distribution Over Pipe
Tee
1dM Pipe 0 0 0 0 0
Aggregate Perforated Pipe Below
r Beneath Pipe -
a Coupling Terminating At
q Bottom Of System
l -