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Form - S T C - 104
t 4
AS BUILT SANITARY SYSTEM REPORT
OWNER IPDA) Zoff l *'it1 TOWNSHIP SEC. J 3 T N-R~W
ADDRESS TW/y 0~4~f ST. CROIX COUNTY, WISCONSIN
#vl2S-z~ CcJi S .
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
19 31
3
_ A_Q ;S /lr~S 2
113
'
76
n
SVpuk
yo~
y
j INDICATE NORTH ARROW
Cut V4-fAc-
7~
BENCHMARK: Describe the vertical reference point used 1 .d
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: CJ~~ Liquid Capacity:
Number of rings used: NOW- Tank manhole cover elevation:
Tank litlet Elevation: 1041 Tank Outlet Elevation: 103• ~-2-'
Number of feet from nearest Road: Front,~Side 10 Rear, C) 7 A feet
i
from nearest property line Front,0Side,0Rear,@ ~p 0 feet
r
Ia
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
Sri, R1?VF12SF Sfm,
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump M>Man--Icturer: Pump/Siphon ufacturer: Pump Size
Elevatottom of tank elevation:
Pump off switch tion: Gallons per cycle:
Alarm Alarm Switch Type:
Number of feetfrom 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
P
Bed: Trench:
I -L 3
Width: Length: ^ Z' Number of Lines: Z Area Built:
Fill depth to top of pipe:
-7
Number of feet from nearest property line: Front, O Side, Rear, Opt. 71
Number of feet from well: 1-/7,3
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Nu er of pits: Diameter:
Liquid depth: B om of seepage pit ele n:
Area Built:
Has either a drop box Pec or d istri ion box O been used on any of the above soil
absorbtion sytems? (Ck on
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of .
Elevation of inlet:
Number``of feet from nearest ert line: Front, O Side, O Rear, O Ft.
er of feet. from well.
Number of feet from building. _
Number of feet from nearest road:
Alarm ranufacturer:
Inspector: HOMESITE SEPTIC Ntumt,''.
u )[R -
Dated: _ Q Plumber on job: ROBERT ULBRICHI
INIS MASTER PLUMB6RLIC Nit;
MINN. INSTALLER & DESIGNF,
License Number:
HOME-SITE SEPTIC PLUMBING CO.
RT. 3 O'NEIL RD., HUDSON; WIS. 54016
ROBERT ULBRICHT
/84 :mj WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
MINN. INSTALLER & DESIGNER LC. NO. 00663
r
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADIS 0 r,S, WI 537b7
❑ALTERNATIVE IS,,,, Plan I ,D_ Number
CONVENTIONAL (
If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAMEbF PERMIT OLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Ron Lunigren 715 Michaelson, N. Hudson, WI 54016 30 - _3?4z
BENCH MARK (Perma-, retere 1~ point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF-PT. ELEV.
NE SE, Sec. 33, T29N-R19W, Lot#ll,B1k.#I,Countryside Vill.Twn. of Hudso
Na- of Plumber. MP/MPRSW No. County Sanitary Permit Number:
Robert Ulbricht 3307 St. Croix 49426
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELE V.. I-
Ltb LABEL JLOCK!NGCOVER
RI~OVIJ DEDPROVDED.
Z` I ~JYES ❑NO ❑YES ❑NO
FRESH
BEDDING. :aVENT PIA VENT MAT L. JHIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT T INLET
e r^ ALAH FEET FROM y uNE; IL 7 LAIR T O F
❑YES r ❑YES ❑NO NEAREST 31, /
DOSING CHAMBER:
MANUFACTURER JBEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING ABEL LOCKING COVER
XJ
PROVIDE PROVIDED:
❑YES ❑NO ❑Y ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND coNraoLS OPERATIONAL NUMBER OF PRO; rv L f BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LI AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NGUf D M ER M ERIAL 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. LENGTH NO. OF pISTR PIPE SPACING COVER JINSIDE DIA 'PITS LIQUID
BED/TRENCH TREN,NHES MATERIAL: DEPTH.
DIMENSIONS 12- .SZ 4 PIT
GRAVEL DEPTH FILL DEPTH IDISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. ISTR NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOV CgqOVO ELEV. INLF f ELLEEV. END C PI S FEET FROM LIN I AIR INLET.
7,72- NEAREST- ~lo
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 ERMANENT MARKERS f OBSEHVATION WELLS
❑YES i NO ❑YES ❑NO
DEPTH OVER TRENCH'BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL ]SODDED - SEED MULCHED
CENTER EDGES
❑Y S NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING . RAVEL DEP H BELO PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
i
MANIFOLD PUMP MANIFOLD DISTR. PIPE' JANO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA. ELEV.. PIPES. DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY C MATERIAL ! pLANSCAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUI LDING.
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
1 r:t J_ 12 , 0 7
1-
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHR SBD 6710 (R. 01/82) ! / !
r
wlsconsln APPLICATION FOR SANITARY PERMIT
I D 1 L H R ty COUNTY
OE RRR' nEnT OF (PLB 67) UNIFORM SANITARY PERMIT #
InOVSTRV,LR90R6HLITRn RELRTIOnS
4/ 9 "7(
-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 CITY:
VILLAGE:
1/4 5Z- 1/4, S T N, R E (or) W ' TOWN OF:
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. L i ❑ Public (Specify):
THIS PERMIT IS FOR A:
New System ❑ Tank: Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
I-] Alternate System U Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
X] 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
L l An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total 0: of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity I'D 1
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: t f=`4, ~t (~it 9' C~~•' ;
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 IS are Feet): 62- 51 ~l J1 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
MP/MPRSW No.: Phone Number.
Name of Plumber (Print): / Signat lye 133 o :7 1(713),WncE~
Plumber's Address: ~C•~ Name of Designer:
f COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
_ J a o `~Jr f_~/ A ❑ Owner Given Initial
,y( 6 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
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 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.
I
Form - S T C 100
Owner of Property
Location of Property-k-'c _~41e Section_,3_,T &--Y N It W
Township
"!ailing Address r~? _ 1
Subdivision Name p„,
Lot Number_
Previous Owner of Property
Total Size of Parcel.
Date Parcel Was Cruatcd
Arc: all corners l.dec►tif Lable? Yes No
Include: w i t h t h i s a „liorlt ion one of thu fulli,wind:
.Certified Survey Map
.Deed
.Land Contract, or
.Other i:egal Document which describes the property
NHOPEHTY 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) tha owner(s) of the property described in this
information form, by virtue of a ►r~arranty decd recorded in the Office of the
County Register of Deeds as DOL011-1011t No. ; and'that I (wu)
prn:A,;uiy own the propused site ku the :rrwage disposal system (or I (we) hava
olAd►Il0d an adSarrltfnt, to run with .hu above described prof'oerty, for the
conbtruction of said system, and th,i same has huan duly recorded in tho Office
of the County Hegiiter of Deeds, as Docu lent No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLEI
.242
y
uArE SIGNED DATE SIGNED
'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, G DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 53709
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCAT•1ON:54_ SECTION: JT~qWNSH_l P /MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME
/4 / /T N/R~~ E W
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS
Residence ~3 /t/4- New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
[KI S❑ U KJ S❑ ~ U ❑ S Z U El S❑ U `'c1xjW 071,), 41 J -C / Y - '
/tii+,i,"YU,A1 ~ 1p/ ✓~Q7
If Percolation Tests are NOT required DESIGN RATE: nrI If an
y portion of the tested area is in the f~
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: "U
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
2'v f~._P. s
B z ~N. 15 B,v. 15 1,S' o~ ham, -5 w-ice /s
C Elf S 6 ~'S c~i 1 f~,T dc~'eS S~
z 1 p DG<!%v , ~S yl
s
B is o or os b,4-,
B~ /7'BN, S/ 1.1141 ~ huff''. s-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 __PERIOD 2 PERIOD 3 PER INCH
P Soi'L 9,0,,r-7W6 U fr f jtL L~ _5_(' .5_ /NP/ . 4% 1e,4f 1 _5 C t eE_
P- >l 171r Q 5 5'.
Ep /A)Gh P~ Q/f
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. ~O? ~t?/ti'( Q-~ f f 1~ ~,t'CtJlJ~/~D~(J _ f ~i ~ r 7 .
SYSTEM ELEVATION
-
F I
1
3 see /f7`'T~ - -
.
E E
E
, N
I
'This tait st e-APPROVED,
-for system.
or conventional septic
I
1
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 (print): IT0WST" TES i 11V
STATE !1N
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
MINNESOTA LICENSE NO. G'13663 ~ ~ d2 y- 31f26 - 00j C
WISCONSIN ble&fSE CST SIGNATU E
R:
T. 3, O'NZL RD.$ HUDSON, W1 54016
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DII-HR-SBD-6395 (R. 02/82) OVER -
T u.'s, section u . M? M Est€:Ecm wilWh WAs in a f y WWWO or -:;omYTIe?'t; s pTttde"'
iMd Ax 0"' R-!1=1 tltlCS be,, 0f hll dr;4r MIS M CF "TE, i .4 1u t7cC
Wrt_, .u thu wZaM rr g s_n x S! .S Sl. l FOR /k s' OLDING ea ®1K ONLY I ALL
CHEER SY sl vE..ME ATE RULE O_, I: EPNt .:way M
PLEASE we qw `#N .,,;:lIt9t,; M,! i ',,v itinq mW= =:fk .C.Oy v S_ w l completing his Vilo plan;
HAKE A LEGITE tfbo a_ ° awwti Ay ` x,r hg yory m, ,r c.. Linn , D &,st;ny is scale is prof rid, t
Mf[ u;.re you I;u31„kM a w a .fE,si3Q s l vainn tetct'e nm utc Clr t65, Mw t, wal aic r7r:rni,ai nt,
A ' Eo m on ( , 1 E , , f u n, w "s am) does not 2ti,ro p . ,._A. t''} tax„ £3pp . pilaf • hux`
. t! cep°=l! r`.i" ss~T ~~t- F 1 t) 3=,it r g
mss v-r . A..€a:_-
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pftpos, o wgu- mv6r LiE 5o Fr a~ tio~~ F~Pa~
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Soil T~~ l Fresh Air Inlets And Observation Pipe
so,L TESTINg By
HOMESITE TES!NG +,0, - Approved Vent Cap
RT.3, O'NE;L iRo:-")
HUDSON, WIS. 1:4016 Minimum 12" Above
Final Grade
/ 1+
4" Cast Iron
Above Pipe Vent Pipe
1o Final Grade
Marsh Hay Or Synthetic Covering
f~ fl Min. 2" Aggrje Over Pipe
Distribution
11 0 0 Tee
Pipe F0
AggregaO Perforated Pipe Below
Beneath Pio Coupling Terminating At
Bottom Of System
POINT OF MATCH LINE - SHEET 2 SOUTH LINE OF SE 1/4 MATCH LINE -SHEET 2
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