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Fo rm - S T C- 1 14
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. I W
AI)llRESS~ ! q0 ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW NoV~~/VFIJ
Y) 201984
ION jN -
Di-stances and dimensions to meet requirements of H 63 10NING
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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j INDICATE NORTH ARROW-
BENCHMARK: Desl.ribe the vertical relcrcu~, ;,pint useu
Elevation' of vei tical reference point: U 3 , to Proposed slope at site: S
SEPTIC T-' K: Mz nufacturer: A/C S G Liquid Capacity: ' U U ea I
Number of rings used: Tank manhole cover elevation:
Tank [nlet flevation: Tank Outlet Elevation:
Numbe-- of feet from nearest Road: Front,0Side ,0 Rear, _ feet
From nearest property line Front,0 Side,0 Rear, _ feet
Numbcr of feet fronj: well building: _
(Include this information of the above plot plan)( 2 reference dimensions to sept
SEI; REVEI:SF, S F DI,"
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,0 Rear , Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: Trench:
Width: Length:-" i Number of Lines: y' Area Built: Ik
Fill depth to top of pipe:
Number of feet from nearest property line: Front,Side, e Rear, oltt.
Number of feet from well:
Number of feet from building: 2
(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 C) or distribution box (:3)been used on any of the above soil
absorbtion sytems? (Check one).
BOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, 0 0 Side, Rear, 0Ft._
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector-.
r,
Dated: : Plumber on job: ~ L .
License Number:
3/84:mj.
DEPAR'TMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O~, BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, O, 53707 BUREAU OF PLUMBING
XCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned)
NAME OF PERMIT HOLDER
ADDRESS OF PERMIT HOLDER:
INSPECTION DATE
Toff A612 R. R. 2, I~ox 140, Hudson, W1 a,
BENCH MARK (Permanem reference point) DESCRIBE IF DIFFERENT FROM PLAN
EF T. EL CST REF. PT. ELEV.:
NE NE, Section 31, T30N-R 19W, Town a4 St. Jv6 eph.
Name of Plumber_
MP/MPRSW No.. County Sanitary Permit Number:
Stephen Aaby 5184 St. CliLoix 58861
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL
LOCKING COVER
P,XI'DE D
BEDDING : PROVIDED:
V v l ` L, YES ENO DYES
: VENT DIA.. VENT MATL. HIGH WATER nlp
ALARM
NUMBER OF ROAD r ROPERTV, WELL BUILDING VENT TO FRESH
EYES p FEET FROM / IAIRINLEr.
DYES ENO LINE
NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
OYES ENO PROVIDED PROVIDED
GALLONS PER CYCLE: PUMP AND coNTROLS OPERATIONAL OYES ENO E ]YES ENO
(DIFFERENCE BETWEEN NUMBER OF PRQPERrY wELL BUILDING IVENT TO FRES
PUMP ON .
AND OFF) FEET FROM LINE AIR INLET
DYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FNC;TH DIAMETER 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 WIDT" LEN. r" "o. of DISTR. PIPE SPACING COVER
TRENCHES M E INSIDE CIA LIQUID
DIMENSIONS L; PIT =PITS
DEPTH
GRAVEL DEPTH
BE LOW PIPES FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL NO •I RISTARL
r ABOVE CO,VgR. ELEV. INLET ELEV. END NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
✓ -L PIP S FEET FROM uNE
AIR INLET.
NEAREST--s
MOUND SYSTEM:
Mound site plowed perpendicular to slope
and furrows thrown
upslope: rpedi Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES E NO meets the criteria for medium sand. 1"IONS MEASURED.
SOIL COVER TEXTURE
PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVERrRENCHBED ~FG OVER THENCH:'BED - DYES ENO DYES ENO
CENTER DEPTH OF TOPSOIL SODDED SEEDED
MULCHED
EYES ENO DYES NO DYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES
DIMENSIONS
. TM'F H ABOVE COV ER
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PON PIPE MATERIAL & MARKING
ELE VATION AND ELEV ELEV DIAELEV. PI PE S
[DISTRIBUTION
INFORMATION "OLE SIZE HOLE SPACING DRILLED CoRRECr LY
COVER MATEIALLIFT CORRESPONDS TO APPROVED
COMMENTS: PERMANENT MARKERS E]YES ❑ NO YES ❑ NO
Ts~HUN WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
YES ❑ NO ❑ YES 1:1 NO NEAREST
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Sketch System on
Reverse Side. Retain in county file for audit.
rSSGNATURE: TITLE.
DILHR SBD 6710 (R. 01/82)
® wlsconsln APPLICATION FOR SANITARY PERMIT - Pi L. H _'Z; 1 C //~~e,,/x COUNTY
r EnT OF (PLB 67) UNIFORM SANITARY PERMIT #
InOUST q V, LRBOR 6 HUM- RELRT10n5 /Jn
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x I I inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
S
PROPERTY LOCATION CITY:
VILLAGE:
E141 114, S,-?/ , Ve, N, R (or) W owN o
LOT NU BER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN .D. NUMBER
,v O /d Cjo , d s T
TYPE OF BUILDING OR USE SERVED 14e - 090
I or 2 Family Number of Bedrooms. Public (Specify):
THIS PERMIT IS FOR A:
eNew System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
i❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
lp"Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued -
E] 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: tA_1Z1r_g4?'q
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 Fleet): PROPOSED (Square Feet):
J/9
Q 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.: Phone Number:
STS y ( 7/67
Plumber's Address: Name of Designer: 100, ,Or / -7' v .Z- ~ U c told d ,d
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
J~ ~ ~y~ ❑ Disapproved
El ,I,- G + /C,2•Lti Z Approved Owner Given Initial
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
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/contracto-c,("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
Location of Property', Section?/ T N - R W
Township
Mailing Address
Subdivision Name
d(Jr~rj
r
Lot Number Previous Owner of Property
Total Size of Parcel
Date Parcel was Created y _
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and. Page Number -.)C-) as recorded with the Reg -
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warzanty Deed
Land Contract
3. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if avail-able, 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
1 (We) eetti6y that a T stat.ement6 on this 6otm ate thue to the best ob my (out)
knowledge; that I (we) am (ate) the ownet (6) o6 the pnopehty descA bed in thus
in6otmation 6orem, by v,vetue o6 a wattanty deed teeoreded in the OA6ice o6 the
County Regtet o6 Deeds as Document No. and that I (we)
p.te,sentey own the p&oposed site. {ion the. sewage pops sys-tem (ore I (we) have
obtained an eabement, to tun with the, above deset,ibed pnopetty, 4ot the
eonvsttuction o6 said .bystem, and the same h" been duty heeotded in the 044.ice
o4 the County Regizte_A oA Deeda, as Document No. ) .
SIGNAT OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
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ST C- 105 r"
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SEPTIC TANK MAINTENANCE AGREEMENT H
0
St. Croix County z
d
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OWNER/BUYER
c~
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP `,,Y
PROPERTY LOCATION:- 14, 4, Section, T N, R_W,
I
Town of-/~ 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 Ior
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
0
I/WE, the undersigned, have read the above requirements and agree n
to maintain the private sewage disposal system in accordance with x
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.
SIGNED
i
DATE
St. Croix County Zoning Office
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&BUIL
INDUSTRY, DIVISION
LA30R AND PERCOLAVON TESTS ¢r's°g DIVISON
HUMAN RELATIONS (115) P.O. BOX 7909
(1163.09(1) & Chapter 145.045) MADISON, WI 537C7
LOCATION: SECTION: TOWNS HIP/AA64WAPA{_~~, LOT NO.: BLK. NO.: SUBDIVISION NAME:
NE V4 4/)/4 31 /T 3o N/R41(or) W S7 ✓asE / CE,e~; s'No f
COUNTY: GW+II4 BUYER'S NAME: MAIL NG ADDR SS: --y~~
S7"C,Pol TE,e,P D ~l70,s0 /rJ GtJ ,r~o~6
USE i
N0. BEDRMS.: COMMER AL DESCRIPTION: DATES OBSERVATI NS MADE
PROF DE IP IONS: ]ON TESTS:
Residence 3 • / New ❑Replace/Q J~✓
/V !f .~d I
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANTK:REC-Oa-MMl/ ENDED SYSTE o nal)
❑ U N S❑ U ❑ u Z S M U ❑ S U vFN7is~'. ~ B E,p 1
If Percolation Tests are NOT required DESIGN RATE:
/ n If any portion the tested area is the A11,4
under s.H63.0915)(b), indicate: IV Floodplain, indicate Floodplain elevation: .Sc C2 PROFILE DESCRIPTIONS
BO ING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) _
/ /08 /D ¢ Z N0A1-- 7 /d 6
LB- o2 /44,3 NONE /O2 2 ~zda~b all
4 Bin ~ ~ 7
B- 3 96 /0 7.2 No ve
B- 96 96,5"' Nv NE
9 6 6 0 o~a~c 6 Qt"r
011 Ale NE 7 ~6 6 B» 6 O cest~ o
B /2 d /I A E ] /2
/D O No.v f ~a 8 /2 ~i ¢ L di a!
B-
/0 No N E /2 0 q,z
B f 96 9 it/eA✓~ 7 96 -~9~
PERCOLATION TESTS CZIIII S',S 114
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEI.-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P RI RI D R PER INCH
P- l 9 Na' 3a
P D 3 ¢9
P- S O / /
P-
P-
?LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
contal 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 Azree,yA e- ? °
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s~ E( s ~r 104- l 1
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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 bast of my knowledge and belief.
NAME (print : TESTS WERE COMPLETED ON:
A Z?7 ~ ?1,4lI 4
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
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CST SI`~U'F~E~
OISTRIEUTION: Original and one copy to Local Autharity, Prope, iy ,_f Snil Tester.
~ILHi ED-6385 ; 02/82) OVER 7-
DaF~?
OGDEN ENGINEERING CO.
Civil Engineers & Land Surveyors
123 East Elm Street
RIVER FALLS, WISCONSIN 54022
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