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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
{f i TOWNSHIP SEC. s, T N-R % W
ADDRESS o ST. CROIX COUNTY, WISCONSIN
P
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
.V ~l~c! Sr
13b
- - - pp ~ 41+1
i!
r
i
1
INDICATE NORTH ARROW
BENCHMARK: Despribe the vertical reference point used
Elevatiop of ve -tical reference point: Proposed slope at site:
SEPTIC Ti1NK: M. Lnufacturer : Liquid Capacity:
lC~nl%
Number of r.ngs used: Tank manhole cover elevation: FZ -3
V Tank Inlet 11evation:T j Tank Outlet Elevation:
Number of fi:et from neG.rest Road: Front,O Side, Rear, O
feet
From Learest property line Front,®Side,O Rear, O feet
L
Q Number of feet from: well building: Z3,
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Ma facturer: Liquid Capacity:
Pump Mo 1: Pump/Siphon Manufacturer: Pu ize
Elevation of i et: Bottom of tank elev n:
Pump off switch eleva n: Ga ns per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nea t property 1 Front, Q Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include di,ptances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: X Trench:
Width: Length:_;~_ Number of Lines - 3 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:
Number of feet from building:
(Include distances on plot plan).
'EPAGE PIT
e: Number of pits: Diameter:
Liquid epth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box O been used on any f the above soil
absorbtion sytems? (Check o
HOLDING TANK .
Manufacturer:. Cap ity:
Number of rings used: Elev of bottom of tank:
Elevation of inlet:
Number of feet from near t property line: Fron O Side, O Rear, O Ft.
ber of feet from well:
umber of feet from building:
umber of feet from nearest road:
Ala Manufacturer:
i
Inspector.
Plumber on job:
Dated:
License Number: 3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS
DIVISION
MADISON, WI 53707yy BUREAU OF PLUMBING
41 M CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound IIf a-fined)
NHOLDER. ADDRESS OF PERMIT HO LDER.
s v cFz INSP. I N D TE
1021 a 4h S., Hud~on, CVI
manent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
T29N_R 19W, Town o6 St. Jolseph F PT ELEV. CST REF PT ELE
Section C7
MP/MPRSW No County Sanitary Permit Number:
Donavi n Schmitt 3205 St. CtLoix 58891
SEPTIC TANK/HOLDING TANK:
M1".A NUF
ACTURE
R
L;LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
/ PROVIDED. PROVIDED
1 `t VYES LINO ❑YES LINO
BEDDING: VENT DIA.: VENT MAIL. HIGH WATER
c I ALARM. NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
YES LINO FEET FROM J LI" > AIR IN ET
❑YES LINO NEAREST / /7 6t' ,a ll `
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
❑YES LINO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMPANDCONTROLSOPERATIONAL ❑YES LINO ❑YES LINO
(DIFFERENCE BETWEEN NUMBERROOF PR OPERrv wELL BUILDING IVENT TO FRESH
FEET FM LINE AIR INLET.
PUMP ON AND OFF) ❑YES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing t FNI,nI DIAMETER MArEHIAI 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 JIDISTR. PIPE SPAGIN(I COVER INS )E DMA -PITS LIQUID
TR ENCyIES.
DIMENSIONS MATERIAL: PIT DEPTH
L ✓ t: I
GRAVEL DFPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. I H NUMBER OF
BELOW PIQHS , ABOVE COVER ELEV INET ELEV E PROPERTY WELL. BUILDING: VENT TO FRESH
f; / ~ l ' ~ I f ~ / I PIP i FEET FROM LINE: AIE INLET
( I NEAREST-s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES LI NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE =RS OBSERVATION WELLS
DEPTH ovER TRENCH aED DEPTH ovER TRENCH aED LINO ❑ YES LI NO
CENTER DEPTH OF TOPSOIL SODDED jS11DED MULCHED
EDGES
❑YES LINO ❑YES LINO ❑YES LINO
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 DISTRIBUTION PIPE MATERIAL & MARKING.
ELEVATION AND ELEV ELEV DIA ELEV' PIPES DIAa
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES LINO ❑YES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE.
❑YES LINO ❑YES LINO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE:
I
DI L H R S B D 6710 (R. 01 /82)
MMMMM2 EZ consln AP PLICATION FOR SANITARY PERMIT ,
:31LHR COUNTY
RPM-nEnTOF (PLB 67) UNIFORM SANITARY PERMIT #
USTFi I.LRBOR 6.UmRn RELRTIOnS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP PTY OWNER MAILING ADDRESS
I
OV / o, ~ /
PROPERTY LOCA I IO CITY:
LACij
'N, R / ~ E (or W -
Ci'1 /4 lr l /4. S T. ~oF_ 57 7,
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
A -'t
TYPE OF BUILDING OR USE SERVED oso- 7j-a;4 16,;t3
1 or 2 Family Number of Bedrooms: _3 Public (Specify):
THIS PERMIT IS FOR A:
N New System ❑ Tank Replacement ❑ Repair
L~ Replacement Soil Absorption System ❑ Revision ❑ Privy
Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
A 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: 7 "
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total # f Prefab. Site Steel Fiberglass Plastic
Gallons Ta s 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):
[ 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 M MPRSW o.: Phone Number:
Plumber's Address: Name of Design`eerr~:
'1 T : / 9
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: ~'y+ Fee: Date: ❑ Disapproved
V~ / 0 te([/,(/ 4-4 4 (jtL ❑ Owner Given Initial
c. ~ f~ 9~ -~3~ "a T Approved 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.
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 01 4i L
Location of Property . LV W"-' '4, Section T N - R W
Township % t
T
Mailing Address [,21 ~4 . AG Q,5,-/y ZZ,
y
Subdivision Name
Lot Number '
Previous Owner of Property ee-A/
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable?` Yes No
Is this property being developed for resale (spec house) ? Yes X" No
Volume and Page Number Z yL,_ 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) coLti 6y that att statements on this 6ohm ane tAue to the best o6 my (ouA)
knowledge; that I (we) am (ane) the owneh (s) o6 the pnopeh ty d" c lbed in this
in6o4mati..on 6oAm, by viAtue of a wa4Aanty deed teco&ded in the 046ice o6 the
County RegisteA o6 Deeds as Document No. ; and that I (we)
ptesente.y own the pnoposed site bon the sewage dispo.sFL eystem (on 1 (we) have
obtained an easement, to Aun with the above desch.ibed pnopenty, 6oh the
constAu.cti.on o6 said system, and -the same had been duty &eeohded in the 066ice
ob the County Reg-i6ten o6 Deeds, as Document No. 3 ~L ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
v~
y
S T C - 105 r
y
H
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
0
y
OWNER/BUYER
ROUTE/BOX NUMBER _I T . _ -Fire Number
CITY/STATE' Lw C - - - - ZIP . _ 2 5
- -
LOCA1'1ON: Ii4, W140, Sect 1.n rr '1' N, R W,
Town of_ St. Croix County,
SubdIvisi -oa Lot number
Improper use and waintenaucc of your scpLic :system could result in
its premature'lailure to handle wastes. Proper_ maintenance con-
sists of pumping Out the septic tank every three years or sooner,
if needed, by a licensed y Lic tank pumper. What you put into
the system can affect the function of the sepLie Lank as a treat-
ment stage in the waste disposal system.
St. Croix County residents iu11 be eligible to receive a grant Iol-
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 rent approximately 30 days prior to
three year expiration.
0
OWE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
H
the standards set forth, herein, as set by the Wisconsin Depart- lu
ment of Natural Resources. Certification form---- ust be/completed
and returned to the St. Croix County l.on'ri Off ce wieliin 30' days
of the three year expiration date.
S I C N E D I DATE
St. Ckluix County Zoning Oft ice
P.O. 3ux
Hammagd, WI 54015
715--716-11239 or 715-425-8363
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUN1CtPAttTY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
1/a, 1/a /T N/R i, 1(or) W /
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
PERCOLATION TESTS:
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIP7-0/1s,
QResidence 1QNew ❑Replace l /
RATIN
G: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑s [:]U ❑s ❑u ❑s ❑u ❑s ❑u ❑s ❑u , t
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-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPT-HN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
C-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-
P _
P-
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
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71
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P ,m-~--- _ _ . - c- T...w....,..,. 1-_..._,.71
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):
CST SIGNATUR :
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER
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ST. CROIX EXCAVATING
ROUTE 2 SOMERSET, WIS. 54025 PHONE 549-6651 ,j