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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP flee SEC./ T N-R ~J PW
ADDRESS 9.~•~c",~~•~/ <;r ~ ST. CKOIX COUNTY, WISCONSIN
7
SUBDIVISION LOT LOT SIZE 1 ,0,3 4 ~
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
LV 1 ~XZH
~I
110
rz
I~
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: 0 Proposed slope at site: / L jv
SEPTIC TANK: Manufacturer: L. t _ Liquid Capacity: Z0~ Cdr ,4
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation:~Tank Outlet Elevation: C1~
l'
Number of feet from nearest Road: Front, Side,O Rear, O~ /
feet
From nearest property lineFront, Side,0Rear, O feet
Number of feet from: well building:
/ 2 4iw? S.I~fs~fch'so-r
(Include *?,is inrc*ra*iar. of the above plot plan)(
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, Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(include distances on plot plan).
SOIL ABSORPTION SYSTEM
6-&4"A6)X02 ;Citti.
Bed: Trench:-- -
Width:__~ ~ Length: Number of Lines: Area Built
Fill depth to top of pipe:
Number of feet from nearest property line: Front, ( Side, O Rear, O Ft.~~_
Number of feet from well: 73 X~
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 syt.ems? (Check one).
HOLDING TANK
n
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:
144 y~
License Number: /
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
~tCONVENTIONAL ❑ALTERNATIVE state PlanLD.N tuber
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Hass gnedl
[NAME OF PERMIT HOLDERADD SS OF ERMIT HO LDERINSPE I N ESam Mittetc 7nau t Btcook Road, Hudson, wT j, ~ 0 cS I 1 v
NCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT R
FROM PLANEF. PTELEV.CST REFPTELEE SW, See.17, T29N-R19W, Lot#96,PwtkView Elst.TV, Twn. of Hudson
Na- of Plurn ber.
IMP/MPRSW Nn.: IC-111y: Sanitary Permit Number.
Doug&6 S;tcahbeen 5432 St. Ctcoix 54911
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
P,R~V}DED: PROVIDED:
1/ J r / YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENTMATL. HIGH WATER
ALARM: NUMBER OF /ROAD: PROPERTY WELL BUILDING. VENTTOFRESH
FEET FROM LINE AIR INLET.
YES ❑NO ❑YES ❑NO NEAREST n f,,' p
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED PROVIDED
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ❑YES LINO [:]YES ❑NO
(DIFFERENCE BETWEEN FEET FROM OF PROPERTY WELL BUILDING I VENT ESI
FEET FROM LINE AIR INLET
ET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth ofplowing LFNC,TH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, constructsgn shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM: r f,
7
WIDTH
BED/TRENCH LENGT 4 No of DISTR PI E SPACING COVER uaulD
TRENCHES t INSIDE DIq Jk pITS
DIMENSIONS I " W AI --•e f N ,TE APIT DEPTH
GRAVEL DEPTH FILL DEPTH IJIST H. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR`
BE LOW PIPE$ ABOVE COVER ELEV. INLET ELEV. END PIPE NUMBER OF PR LINOPE ERTV WELL. BUILDING AIR INLTOET
FRESH
FEET FROM
NEAREST
~J~- /
MOUND SYSTEM: L y
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 rexruRE
PERMANENT MARKERS: OBSERVATION WELLS
DEPTH OVER TRENCH BED DEPTHOVFRrRENCHBED ❑YES ❑NO ❑YES ❑NO
CENTER DEPTH OF TOPSOIL SODDED SEEDED J ULCHED
EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR. DISTR. PIPE UIS TH IBUTION PIPE % ATFRIAL & MARKING
ELEVATION AND ELEV ELEV DIA ELEV.' PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL.
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANE7UAR
KERS
: OBSERVATION WELLS: PROPERTY WELLBUILDINGNUMBER OF LINEES ❑NO ❑YES ❑NO N
FEET FR
EARESOM
Sketch System OR Retain in county file for audit.
Reverse Side.
7
SIGNATURE.
TITLE.
DILHR SBD 6710 (R. 01/82)
wlsconsin APPLICATION FOR SANITARY PERMIT
~ odveaAi~~_4COUNTY (PLB 67) oEaaaTmEnTOI= UNIFORM SANITARY PERMIT #
In OUSTRY, LRBOR 6 HUTRn RELRTIOf-15 ~
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION II 24R'F:
-
A, 1 1/4, S / f , T 1_`- N, R /<1 E (orkJl' TOWN OFD
'LOT NUMBER BLOCK NUMBER SUBDfIVISION 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:
C 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.
2 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: (_-r -I -Z
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
1 Gallons Tanks Concrete Constructed
Septic Tank Capacity !
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inchREQUIRED (Square Feet): PROPOSED (Square Feet): L/N Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Si
Name of Plumber (Print):: na MP/DMPRSW No.: Phone Number:
Plumber' Address: jN;7e.. f Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Disapproved
/ 00 ❑ Owner Given Initial
j'~ 4•-C,~(G P /`f C (/`GijJ (r~ Q'r Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6298 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/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 -
c~-
Location of Property Section, T N - R -~i--~
Township
Mailing Address 116 0 1P c Q 2
Subdivision Name( V--to.
Lot Number
Previous Owner of Property
Total Size of Parcel,
I)ate Parcel was Created
Are all corners and lot lines identifiable?_ Yes No
Is this property being developed for resale (spec house) ? Yes No
it-
Volume
and Page Number 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.
PROPbRTY OWNER CERTIFICATION
I (We) eentiU y that a U- statements on ,th,iz 6ohm ane tAue to the best o ~ my (ovA)
hnowkedge; that 1 (we) am (oAe) the owneA(a) o~ the pnopenty dactibed in this
in6o,,mati.on 6oAm, by viktue ob a waAAanty deed &eeonded in the 046ice ob the
County Regi~s-teA o4 Deeds " Document No. a!, 3cj and that I (we)
pkaentX y own the pnopo.6ed site 6oh the hewage dispo6at b ystem (oA I (we) have
obtained an e"ement, to nun with the above de6cAibed pnopescty, 4oA the
eowstcuction o6 said system, and the same has been duty rLeconded in the OA64'-ce
o6 .the. County Regi6teA os Deeds, as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
" U1
H
y
S T C - 105 r
r
y
H
SEPTIC TANK MAINTENANCE ACREEMENT H
O
St. Croix County
c7
OWNER/JiUYlilt
ROUTE/BOX NUMBER !WOK Fire Number
CITY/STATE' fl,; l r t 1. Lr ~,-yUl
11 RUPER'I'Y L0CAT10N: "4 , 4i, Section 1 N, R -w-
Town of b",~~5~. -r- St. Croix County,
Lot number
Subd iv is.to~ r~' >9~
I
I
1❑i1) ro1) eC nSe and III aintenanCt of your sepLiL' system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or souuer,
if needed, by a licensed seLLic tank 1_uIli l)er. What you put into
the system can affect the [unction of the_ septic tank as a treat -
ment stage in the waste disposal system.
St. Croix Cu uuLY residents may be eligible to receives' it )!,raiit fur
a maximum of 60% of the cost of replacement of a lailiug sysLeui,
which was in operation prior to .July 1, 1)78 St. Cr.uix Cl_,unty
accepted this program in Aui;ust of 1980, with ttie requirement that
owners of Ili new '~Y_stem:i al~,ree to keep the i r systems proper) y
maintained.
The property oWnC r agree:; Co subunit to SL. Cr0iX CoUi1Ly Z.>>riilg a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumb-.ar 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
I/WE, the undersigned, have. read the above. requirements and agree
to maintain the private sewage disposal system in accordar..ce with x
the standards set forth, herci-n, as set by the Wisconsin UeparL- v
ment of Natural- Resources. CC rtl.fiCatioIt form must be completed
and returned to tIt e St. Croix County Zoning Office within 30 days
of the thrUC year expiriitiou date
SJGNE ti~ Itis
ll AT 1? - ,Z
St. Croix uuty Zoning 011 1 ce
P.O. Lox 98
Hammond, W1 54015
715-796-22311 or 715-425-8363
Sign, date and return to above address
DEPARTMENT OF REPORT ON SOIL BORINGS AND A~ GS
ET IIVLDIISIN N
INDUSTRY, dG ON
LABOR AND PERCOLATION TESTS (115) P. X 7969
HUMAN RELATIONS Q ~y~y~(I,P9~ccDuy$O 153707
(H63.090) & Chapter 145.045) V
LOCH ION: SECTION: STOW HIPWUM+-e P y: LOT NO.: BLK. N UBDI N N E:
/ /as '/a /T~"N/R/7~'(o W r sC /q1/Q s
COUNTY: W ER'S/BUYER'S NAME: MAILINGADDRES :
USE
DATES OBSERV TIONS MADE
NO. BEDRMS.: COMMERCIAL ESCRIPTION: , PROFILE DESCRIPTIONS: PERCOLATION TESTS:
esidence ~ New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system 5Z
ltr ;l d
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FIL H LDING TANK: RECOMMENDED YSTEM:(optiona
Ks ❑U KS ❑U S ❑U ❑SXU ❑S RU d~
Funnders.-163.09(.09(5) rcolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
(b),indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
.C.9 I
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER•
CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
ye,
~S
B-3 /0,7
B- 7S_ 1,02 sl~~
B- A 01
TESTS
TEST DEPTH/ WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER Fhe"C,S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- /
P- 3
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 percent
of land slope.
SYSTEM ELEVATION
g// t Go~~u4- Xe A, 1'~ , _ L J
e~ corm en- ,~.c -top Or
z
tN
!!2 0
1-J, wl a a ~e/ rc0
dxav-k tz,&d Air, v
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: 0 all
ADDRES : CERTIFICATION NUMBER: PHONE NUMBER (optional):
CS NA URE: `
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER
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