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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T { N-R~W
E
i
ADDRESSST, CROIX COUNTY, WISCONSIN
SUBDIVISION r LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements f' 11 63
SHOW EVERYTHING WITH 1000 FEET OF SYSTEM
r
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity.
Number of rings used: Tank manhole cover elevation: 1
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,D Rear, feet
From nearest property line : Front, QSide, 0 Rear, 0 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
T Y
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, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Len the Number of Lines: Area Built:
Fill depth to top of pipe:
Ft '
Number of feet from nearest property line: Front, O Side, O Rear, 0
Number of feet from well:
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 sytems? (Check one).
HOLDING TANK
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. 1 Plumber on job.
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
MADISON, WI 53707
ti PP~CONVENTIONAL EALTERNATIVE SfatePlan ID.N,mbe,
Holding Tank ❑ In-Ground Pressure D Mound (1( assigned)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Wes Edgar R. R. , Somerset, WI 54025 if-, fiY._ ~*s~v
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.
SE NE, Section 21, T31N-R19W, Town of Somerset
Name of Plumber: MP/MPRSW No County. Saon ly Perm,( Number_
Cal Powers 1563 St. Croix 54940
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: AR NG LABEL LOCKING COVER
1 ~ O 11 ED PROVIDE `
t ? YES ONO ❑ ES 10
BEDDING: VENT DIA VENT MAT L: HIGH WATER NUMBER OF ROAD: JPINE~:J) ROPERTY WELLt BUILDI VENT TO FRESH
ALARM
FEET LAIR INLET.
OYES NO DYES ONO NEARESTOM
DOSING CHAMBER:
MANUFACTURER: BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MAWFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ONO / OYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: N MBER OF P OPfrRTV JWELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE IAIR INLET'
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing jl_v ]TH JDIAMETER 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 WIDTH LENGTH NO OF DISTR PIPE SPACING COVER INSIDE CIA -PITS LIQUID
DIMENSIONS TRENCHES MAT Tp IAL'.- PIT - DEPTH.
_ l
GRAVFL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. $TH NUMBER OF PR OPERTV WELL, BUILDING. VENT TO FRESH
BELOW PIPES ABI VE COVER ELEV INLEr ELEV. END _ PIPE$ 7 FEET FROM LINE; AI LF,T:
n
NEAREST
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 m ke certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for dium sand. TIONS MEASURED.
OYES ONO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
OYES ONO OYES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH.'BEL) DEPTH OF T PSOIL SODDED SEEDED MULCHED
CENTER EDGES
DYES ONO DYES ONO EYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVFR
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR jD;STRPIPE DISTRIBUTION PIPE MATEHIAL & MARKIN
ELEVELEVDIAELEV.' PIPESDA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING
FEET FROM LINE
1 j = DYES ONO OYES ONO NEAREST
c• I
Sketch System on
- Retain-4n county file for audit.
Reverse Side.
SIGNATURE. TITLE.
7
DILHR SBD 6710 (R. 01/82) = fem.
r
wisconsin APPLICATION FOR SANITARY PERMIT
.DILHR (PLB67) COUNTY
oEPFRTTT1EnTOF UNIF ANITARY PE MIT #
~1- InOUSTRV,LABOR 6HUMRn RELRTIOnS
-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 LOCATI-ON CfTY-
i VILLAGE:
1/4/1".' /4,S T J, N, R i"VIE (or) W TOWN OF: r
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED _ O3a lQp - C/
1 or 2 Family Number of Bedrooms. Public (Specify):
THIS PERMIT IS FOR A:
❑ 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.
❑ Seepage 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
❑ 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:
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):
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): Signat MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
f ~/Q Zl / 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
i
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 r
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.
APPI,ICAT ! ON I'01: `;ANI TAIZY V!,' V I T
s T C - I00
This app' i cat ion form 1s to be comp! er ed i n f ti': ) <inci s igfiled by the owner(s) of the
property being, developed. Any inadequac;-, will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor,("spec
douse"), 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 M3 (z-i EJgcky- _
Locat ion of Property A W ~4, Section T 3 N - iz W
Township
Mail ing, Address y-
Subdivision Name
!,o t Number f - -
Previous Owner of Property ~j (2 v. Vyl- ~~L e S e
'T'otal Size of Parcel 3 . I ACrt -S
!)ate Parcel was Created 17 (-,A f Ov, a lf?2 '
Ar(~ .il 1 corners and lot lines identifiable? ✓ Yes No
is tl)i.s property being developed for resale (spec house) ? Yes No
VIC IM1e ~ and Page Number 7 3j as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE. FOLLOWING:
Warranty Deed
2. Land Contract
4. 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
Y (We) ce.,~_t,(.f y that, ak(' statement,, on this ~onm ane true to the belst oA w r (oun)
fzviowtedge; that Ir (we) aK (aAe) the owneA(s) o~) the. pA-opvLty d"eh ibed in th.a
(.nAonmatton Konm, by viAtue- o{ a waAAanty deed AecoAded in the OAOice o{) the
County Reg-i~teA o A Deeds aA Doeume.nt No. 33 and that r (we-)
,v).~e,uent~('y own. the pAoposed site ~oA the sewage po,~c✓ 1~y,~tem (oA X (we.) have
obtained an eaAement, to nun. with the above dmnibed pAopeAty, {oA the
eon,~tAuct,%on o{ said system, and the. same hay been dut Ae:eonde.d in the 0{Oice.
o{ the. County Re.g~~teA oA Ceed~, as Doeumen~t No. 3~'~3y
SIGNATURE OF OWNS SIGNATURE OF CO-OWNER ( APPLICABLE)
1)A'1'I 4GN 1) r-, SIGNI?1)
H
U)
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S T C - 105 r
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SEPTIC 'L'ANK MAINTENANCE AGREEMENT o
St. Croix County
d
y
OWNER/BUYE'R W2 Sk'" e 4c _
ROUTE/ BOX NUMBER }~a7C Fire Number ~✓F~
CITY /STATE S9 vv~%r ~e ------Z i P
PROPERTY LOCATION: 9Lv `Z,St_- Section T 31 N, R l t _W,
Town of SD Me~Set St. Croix County,
Subdivision_ tJA 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 pumLer. 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 ma be eligible to receive a grant for
a maxi_nrum 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 stems 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
ti
three year expiration. o
I/WE, the undersigned, have read the above requirements and agree Cl)
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- "i
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 L
DATE ll t
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.
,.xsca,se., SANITARY PERMIT
®1 L H R County
If1OlJ5TAV,LABOA6FRJfTIRY1FmELAT10115 GROUNDWATER SURCHARGE SanitarS 6"
y Permit No.
/ O
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly known as the groundwater protection law. This change in statutes was the result of over
2 years of steady negotiation and public debate. The groundwater bill included the creation of
surcharges (fees) for a number of regulated practices which can effect groundwater. The
surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to
the groundwater through your soil absorption system or the disposal site used by your holding
tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
Ground
Signature of Issuin Agent: Groundwater Fee: Date: Wiscoft~S
buriedt3t r
DILHR SBD-7289 (N. 05184) 1
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t
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDIN
INDUSTRY, DIVISION BOX LABOR AND PERCOLATION TESTS (115) MADISON WI 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
: SUBDIVISION NAME:
LOCATION:. SECTION: TOWNSHIP/M~1PdiCIPALITY: LOT N .:BLK. N
/T (or) W Z
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: ~PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ZNew ❑Replace / f
RATING: S= Site suitable for system U= Site unsuitable for system ; I
CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FILL HOLDING TANK. RECOMMENDED SYSTE :(optional)
WS ❑U ❑S ❑u ES ❑u ❑S ❑u ❑S ❑U _
If Percolation Tests are NOT require 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 DEPTH M. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
71
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER FNCi+ES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERT D2 PERIO 3 PER NCH
P- I
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 horir
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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7
.
3
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%
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41
I, the undersigned, hereby certify that the soil tests reported on this fora were made by me in accord with the rocedures and meth s specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowled and belief.
NAME (print): TESTS WERE CO ET ON:
ADDRESS: CERTIFICATION IZMBER: PHONE NUMBER optional):
CST NATURE.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) -OVER -
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PAGE OF
CruS~ zc~Iv~, o~ 1Set~ Sy5
Fresh Air Inlelc And Obcerrallon Pipe
Approved Vent Cap
Minimum 12 Above
Final Grade
20- 42" Above Pipe _ 4" Cott Iron
To Final Grade Vent Pipe
Morth Nay Or Synthetic Covering
win 2" AQ9royole
Owr Pipe
Distribution
Pipe 0 0 0 0 0 - Tee
Aggtegate
0 Pertoratetl Pipe Below
Beneath Pip e
o -CaVPling Terminating At
Y Bottom Of Sy►lem
Pro ONe D In~.l c~ri,,cl<
cDe.J.j t orl ~E,
SOIL FILL
DISTKI13UTIOr.I PIPE ~~NTN
APMOVED ETIC COVER
o ' "MAT~~i1At OcZ 9" OF STRAW
2"OFgGG9EWE oR MARSU HAS
~iOF ~'/2 AG 6REGATE 008° ~~j
ELEV. OF FEET
DISTRIF~JTIOU PIPE TO BE AT LE15,51 11JCHES BELOW ORIGIIJAL GRADE
AIJU AT LEAST20 IUCHL-S BUT 1.10 MORE THAI) `i2 INCHES BELOW FIAIAL GRADE
MAXIMUM ®EPtH OF FXcAVAT1,00 FXoM OK16WAa (aKAoF- `-,JILL BE IIJCHES
MINIMUM IPF-P t OF EACAVAT1DN FKOM C4KIf,IHAL (39499- WILL BE / INCHES
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SIG"CD:
LICLIJSE uUMBER:
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DATE: 1110
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