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- Form - S T C - 1 04
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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ~ SEC. _ T i N-R W
a
ADDRESS i ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: /i Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: - Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side 10 Rear, O feet
From nearest property line : Front,0 Side,0 Rear, O feet
Number of feet from: well building-
(Include this information of the above plot plan)( 2 reference dimensions ro sonric tink)
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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, 0Side, 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: Length:__ Number of Lines: Area Built:,-,
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft `
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: Plumber on job,:
License Number
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
DIVISION
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
P.Q. BOX 796N BUREAU OF PLUMBING
MAFASON, W'. 53707
.
CYCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
' (If assigned)
El Holding Tank 1:1 In-Ground Pressure El Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Robert McvlteU R. R. 1, Someuet, W1 54025 4/
~U
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV..
NW NW, Section 22, T31N-R19W, Town o4 Someuet
Na-, of Plumber IMPIMPR SW No. Cou n[y Sanitary Permit Number.
Gary Steel 3254 St. Cuix 58858
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOC INfE P V DED. PR ID~~. YES ❑NO ❑NO
BEDDING. VENT DIA.. VENT MAT L. HIGH WATER NUMBER 'OF ROAD: PROPERTY WELL. BUILDING: V T TO F ESH
A LARM. LINE( AIR INLET;
FEET FR ❑YES NO ❑YES ❑NO INEARESTOM Al
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PCONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING JVENTTOFRESH
(DIFFERENCE BETWEEN FEET FRM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST)
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH 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:
WIDTH. LENGTH INOOF IDISTR PIPE SPACING C JINSIDE DIA &PIT$ LIQUID
BED/TRENCH < 2 TREN Es 2 MAT ~AL PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILI. DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. DIY R NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES AB E COVER E E IN FT IV EN PIPES FEET FROM LINEa C / AIR INLE
•~S _ NEAREST
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. "IONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & 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: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE.
3 ❑YES ❑NO ❑YES ❑NO NEAREST
.1.t~ •-1.rj`~
Sketch System on Retain-in_county file for audit.
Reverse Side. 1/ 411, SIGNATURE _ TITLE
DILHR SBD 6710 (R. 01/82)
®w(sconsln APPLICATION FOR SANITARY PERMIT
`®1 L H R (PLB 67) COUNTY
OEPHRlfr1EnT OF UNIFORM SANITARY PERMIT #
InOUSTRV, LRBOR 6 HumRn RELRTIOns 1_~ff 5T
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION CITY:
VILLAGE: /
/l 1/4 1/4, S T N, R,1 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 , -~QS --70--
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 L., 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:
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): Signature: MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
j ~kG pu ❑ Owner Given Initial
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
L I
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
APPLICATION FPO SANITARY I'1?!LM! T
C' T C- c o
This api>li-cat ion 1 orm to be comp" etc'c' i-n ul l and s ~4~ncd by the uwner_ (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 i !r M"• 21T~E l 1, -
Location of Property Rwj ~4 Vkvj_',r, Section T -~A N - R W
Township 2c-w NL%!~ 1'f,5.
Mailing Address LATE,
Subdivision Name.~~
Lot Number A
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are al.l cornere and lot Lines ident i f i_abl_e-"? Yes No
Is this property being deve_'_oped for resale (spec house) ? Yes No
Volume i and Page Number as recorded wl,h the Register of Deeds
TNCLUDE WWII TI-lIS APPLICATION ONE OF THF. 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 Survev
Map, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
nROPFRTV OWNER CERTIFICATION
I (!ale.) ee.Ati" )y that aXt startemen,t6 on this ~onm an.e tAue to the berst oo my (oult)
lmow2edge; that I (we) am (are) the, owner (s) of the pnopvLty de~sn bed in. ,th.i6
In~)onmation 4o4m, by vi)Ltue oo a wvuq-an-ty deed ne.eonded in the. O{()ice. OA the
County RegiAteA o~ Veedis as Document No. j / and that 1 (we.)
pnme.ntt y own the p-, o pas ed A te. ~ oh the .s ewag-~e dis poi a -,,system (ort 1 (we) have
obta.i,ne.d an ease.men.t, to nun with .the above. deAepu.be_d prtopeAty, {ion the.
co"th_uction oA said syAte.m, and .the. same hay been duP-y uconded in the. OAOice
o{ the. County Regi~te•c o~ ~~ee~~S, r~s Poerlme~!t No.
SIGNATURE OF OWNER SIGNATUREi'OF CO-OWNER (IF APPLICABLE)
DA'I'li: SIGNET) DATU' SIGNI D
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ST C- 105 r
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County 1
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OWNER/BUYER
i~ ~ i2.a ~ A ►Z--"t L-_-
ROUTE/BOX NUMBER ,i -Fire Number
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C I Y / S 'I' A T E iz_`~ 'r" i -------'1. LP
PROPERTY LOCATION: AV4 14, Section_'j2, T '~5A__N, R ACJ___W,
I j
Town of C,1 tAC,f2-`~cr 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
I
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 for
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.
0
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I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days i
of the three year expiration date.
S I G N E D
i
--~~rC~ _
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 REPORT ON SOIL BORINGS A ~ /,(A ~ & BUILDINGS
INDUSTRY,*
DIVISION
LABOR
HUMAN AND
HUMA PERCOLATION TESTS (115 .O. BOX 7969
HN RELATdONS A N, WI 53707
X, (H63.09(1) & Chapter 145.045) ~Q.lyC4 j9
LOCATION: SECTION: TOWNSHIP/~: LOT NO.: ~ . NO.: V I S I Nl%#1:
10 W1 '/a M/4 /T N/R /J (or) W _
COUNTY: OWNER'S/BUYER' NAME: MAILING ADDRESS: i
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LC_ ✓ .~1 1-'- -f\ V" Lis ~
USE DATES OBSERVATIONS MADE`
NO. B'RMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence / New =D Re lace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
EIS ❑u s s ❑u ❑ s ~u o S.'--'7U
[under Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
s.H63.09(5)(b), indicate: / Floodplain, indicate Floodplain elevation:
L 1ifYYI~ ( PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEfftt-'N. OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
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B ~e~ ^Ji s to , `moo
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 1ES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ 3 Y-11 3 17
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
Flo to
1-,rrt._>~
k/tr ftv A Ps t;4 4- o 6
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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 best of my knowledge and belief.
NAME (print l: TESTS WERE COMPLETED ON:
!!i'r`7 4f_ - Z - 9' j
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNA7,E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVFR -
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