HomeMy WebLinkAbout032-2001-40-000
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1
UTPORT OF I1?SPECTIO ?--I dDIVIDt.1AL SETV-, TE DISPOSAL SYSTEM
Sanitary Permit
State eptic
m
a.dA?tE i~ ',t ~ TOWNSHIP
St. Croix Count;
S"PTIC TnK
Size
,cG :L _ gallons. ";umber of Cornpart cents ,f
Distance 'From: t:?eIl _Z L_(, ft. 12`To or greater slope ~ wilding ft, Wetlands ri
S 3 1" 1R~•Jcdt2r f4-
DISPOSAL SYSTE14 Tile Field or Seepage Pit(s)
Distance From: ''ell ft.
12/, or greater slope ft
building ( ft. Wetlands ft
FIU'LD 11inhwater ft.
Total length of lines ft. dumber of lines Length of
each line ft, Distance between lines ft. Width of the
tre_ich _ft. Total absorption area
sq. ft. De
pt;
of rock below tile in. Depth of rock over tile - in. Cover
over rock Depth of tile below grade 'in. Slope of
i
trench in ner 170 ft, Depth to Bedrock ft. Dept'q to
ground water ft.
IT
"lumber of nits Outsize diameter ft. T)e.pt% below inlet
ft. Gravel 'a-kound pit:
____yes no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
Square feet of seepage nit--area required
Inspected by Title:
Y
Approved
Date a 1_41_ 19 7 .
Rejected Date 197
Plb 67 State and County State Permit
Permit Application County PerLnLj
for Private Domestic Sewage Systems County C d
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: Section T N, RIV it (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# _ Village
Township 6791 MCA S 6-
C TYPE OF OCCUPANCY: -Commercial -Industrial -Other (specify) *Variance
Single family- Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste GrinderYESA-,-NO # of Bathrooms
Automatic Washer -A YES NO Other (specify)
E. SEPTIC TANK CAPACITY `a Cc) Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement- Prefab Concrete
*Poured in Place
Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)..,? 2)Z 3) Total Absorb Area-.2,$- J' sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. ~ Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length Width ! Depth Tile Depth- No. of Lines ~ - -
Seepage Pit: Inside diameter Liquid Depth Tile Size ~Z
Percent slope of land jP Distance from critical slope %16 A!
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester / j
NAME p 0- C.S.T. # rz and other information
obtained from IN (owner/builder).
Plumber's Signature - MP/MPRSW# Phone # fj S~V
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
if
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Do Not Write in Space Below - FOR DEPARTMENT USE ONLY /
Date of Application s Z7 Fees Paid: State U C~unty to ~k~
Permit Issued/Po-(date) Issuing Agent Name A~
Inspection YesNo Valid# Date Rec'd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 3/1/75
EH 115 (11-74)
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
• P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: _'/4, '/4, Section T-N, R _ E (or) W, Township or Municipality
Lot No. , Block No. County
Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET SOIL TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B-
B-
B-
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. Indicate scale
or distances. Give reference point. Indicate slope.
N
t
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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) Signature
Certification No.
Name of installer if known
Copy C - Local Authority
V I
EDWARD L DALLIER /4`F
V. 356) P. 94
,
20' EASEMENT
V. 545, P. 88a 89
,
WEST
i 2 9 8 _
RAILROAD SPIKE SET IN
ROOT OF A 3 DIA. TREE
i LOUISE BENSON
1 V. 356 P. 95 ~
-1 20
WEST
152.61 145.39
298
' ~to. MELVIN E. PROULX l
V. 47 8 , P. 2 70o
_ N
E A S T
- - - - - - - rn
w 298'
D, 3 o
i
V. 4761 P. 4 07 to
fh
i
SNO FENCE ENCROACHES
EAST
@-
134' 16 4
2, , 2.4'
18~
GEORGE FAGNAN -co BESEAU
-OD _ V.324 , P.449 N V. 483 , P. 212 co
N
O N (
O
134' 164 ' NORTH RIGH'
K)
13 4 ' I K)
i
(ASSUMED BEARING) EAST 1300.20'
STATE TRUNK HIGHWAY "64" M
LEGEP
• PI PE (
- ----4- E X I S T
0 1 "X 24
Parcel 032-2001-40-000 10/29/2009 12:38 PM
PAGE 1 OF 1
Alt. Parcel 36.31.19.468K 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
MELVIN E & SALLY PROULX O - PROULX, MELVIN E & SALLY
727 HWY 35 PO BOX 133
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 727 HWY 35
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 1.010 Plat: N/A-NOT AVAILA13LE
SEC 36 T31N R1 9W 1.01AC IN SE SW COM SW Block/Condo Bldg:
COR TH E 299 FT, N 161 FT TO POB; TH E
298 FT, TH N 150 FT, TH W 298 FT, TH S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
150 FT TO POB
36-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2009 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/03/2008
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.010 16,000 104,200 120,200 NO
Totals for 2009:
General Property 1.010 16,000 104,200 120,200
Woodland 0.000 0 0
Totals for 2008:
General Property 1.010 16,000 104,200 120,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00
0.00
L,
C d d C
07 - 1
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Parcel 032-2001-40-000 03/21/2006 09:54 AM
_ PAGE 1 OF 1
Alt. Parcel 36.31.19.468K 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - PROULX, MELVIN E & SALLY
MELVIN E & SALLY PROULX
BOX 133
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC 1
Legal Description: Acres: 1.010 Plat: N/A-NOT AVAILABLE
SEC 36 T31 N R1 9W 1.01AC IN SE SW COM SW Block/Condo Bldg:
COR TH E 299 FT, N 161 FT TO POB; TH E
298 FT, TH N 150 FT, TH W 298 FT, TH S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
150 FT TO POB 36-31 N-1 9W
Notes: Parcel History:
Date Doc #t Vol/Page Type
2005 SUMMARY Bill Fair Market Value: Assessed with:
77464 149,400
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.010 16,000 104,200 120,200 NO
Totals for 2005:
General Property 1.010 16,000 104,200 120,200
Woodland 0.000 0 0
Totals for 2004:
General Property 1.010 16,000 104,200 120,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
R
Wisconsin Department of Industry,
PLB-1 INSPECTION REPORT Labor & Human Relations
Safety & Buildings Division
Bureau of Plumbing
Name o remises a e an-TD. No.
Street i. y County Sanitary Permit
Master um er Firm Name dress
Journeyman Plumber Address
Owner ress
+ fIr i v.' n
41 d~
6
n
. Wit' .,r A..-L.n ~ w..~t~k '`°h'~-t."" ~ 'ti
f~Ja ,r tom' .T r _
4" _
r
t a
t
7
JUN 21 1984
w m -a_~ _
v&
iscusse wit-h-_
Signature
)See Attached.
DILHR-SBD-6192 (R.10/82) Signature of is Plumbing .u 1 n- e as p; pecia '
Inspector Local Inspector Plumber or Responsible'AParty ner
i r Fo rill -
AS BUILT SANITARY SYSTEM REPORT
OWNER
f TOWNSHIP ri ~r•.'. - SEC. T>,' 1 N-R
ADDRESS 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
r
L~f
r
~f'i
i,
r V
INDICATE NORTH ARROW
BENCHMARK.: Describe the vertical reference point used
Elevation of vertical reference point: h
Proposed slope at site: ,/_i i
SEPTIC TANG.: Manufacturer: 471.
Liquid Capacity:
Number of rings used/2 Tank manhole cover elevation:
Tank Inlet Ele~ati4i
Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,0 Rear, O
feet
From nearest property line Front, 0Side, 0Rear, 0 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
1 ~ l
Cl%
Liquid Capacity:
0
` ---,Z111ump/Siphon Manufacturer: Pump Size
_~vation of inlet: Bottom of tank elevation:
Pump off switclOelevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number, of feet from nearest property line: Front,0Side, Q Rear, Ft.
Number of feet from well: _
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
y,
Width: ' Length: Number of Lines: ~ Area Built:.:.
Fill depth to top of pipe:
Number of feet from nearest property line: Front, -O Side, Rear, Ft Z
Number of feet, froth well;
r
Number of 'f'eet f"rolu building: (Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built.-rte
Has either"a drop box 0 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:
Elevatio/W'of inlet:
Number of feet from nearest property line: Front, O Side,~> Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Plumber on job:
Dated.
T;-nse Number:
f`
3/84:mj
SAFETY & BUILDINGS
INSPECTION REPORT FOR DIVISION
rDEPNRTME-N47T1OF INDUSTRY, BUREAU OF PLUMBING
MAN RELATIONS PRIVATE SEWAGE SYSTEMS
P.O. BOX 7969 State Plan Lo. Number
MADISON, WI 53707 [CONVENTIONAL El ALTERNATIVE ,If assgned)
❑ Mound Tank O In-Ground Pressure
❑ INSPECCTTEI N ATE
ADDRESS OF PERMIT HOLDER: Oar
NAME OF PERMIT HOLDER /~t7 ✓R
Pt~.au,e.x Bax 133, Same et, W 1 REF. PT. ELEV.: CST REF. PT ELEV
Metvin
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. ^a ml'J e
SE SW, Section 36, T31N-RIW, Town aj J Sanitary Permit Number
MP/MPft SW No.. Co"~ry 54916
Name of Plumber' 3254 St. Cnatix
Cany L. Steed
TANK INLET ELEV.. TANK OUT LE.T ELE V.. WARNING LABEL PROVIDED OVER
SEPTIC TANK/HOLDING TANK: uou ID CAPACITY: PROVIOEo-
MANUFACTURER . DYES ONO DYES ONO
BUILDING. VENT TO FRESH
ROAD'. PROPERTY WELL AIR INLET.
VENT MATL HIGH WATER NUMBER OF LINE.
BEDDING VENT DIR.. ALARM FEET FROM
DYES ONO NEAREST
DYES ON WARNING EL LOCKING COVER
.
DOSING CHAMBER: PUMP MODEL PUMPISIPHONMANUFAC, ER PROVID PROV I DED
13E CUING LI IDCAPACIT { ES O NO DYES ONO
MANUFACTURER Y
OPERTV WELL BUILDING (VENT TO FRESH
DYES LINO U1 R OF AIR INLET
MP ND CONTROLS OPERATIONAL. NW L NE
GALLONS PER CYCLE: F, T F
DIA FTEH MATEHIAI AND MARKING.
(DIFFERENCE BETWEEN DYES ONO N A EST
PUMP ON AND OFF) N('T
FORCE
SOIL ABSORPTION SYSTEM. Che k he s it eoisture at he depth of plowintng MAIN
or excavation. (If soil can be Tolle nto a , construction shall cease uil
the soil is dry enough to continue.) DIR #PITS uoulo
IN UE .
CONVENTIONAL SYSTEM: LENGTH No of DISTR PIPE SPACING COVER PIT
WIDTH MHIAL'.
T H E NCLH ES' ~ i.
BED/TRENCH \ i L~ j PROPERTY WELL: BUILDING AIR INLET FRESH
DIMENSIONS C V PE Ut- LINE
PIPES FEET FROM 6 6~U .k I' l'~L~t
T; PIPE (r i
GRAVFL DEPTH ADO RECOVER EEV INLET ELEVR ENDS DISTR. CIAL : NO IS R. NUMBER
BELOW PIPES 7 hNEAREST---0I1
MOUND SYSTEM: PROVIDE A DIAGRAM OF SYSTEM
Mound site plowed perpendicular to slope Check the texture of the fill material for VERSE SIDE. SHOW ELEVA
and furrows thrown upslope: mound systems to, make certain that it ON ON REVERSE
MEASURED.
meets the criteria f r edium sand. TIONS
DNO OBSERVATION WELLS
DYES PERMANE TMA KERS
SOIL COVER TEXTURE ""OR
OYES ONO
YES Mu cHED
VIE E D
DEPTH OVER TRENCH BED EocES ovER TRENCH;eED DEPTH of TopsolL SODDED D N D YES O NO DYES D NO
CENTER El Y
FILL DEPTH ABOVE COVER.
PRESSURIZED DISTRIBUTION SYSTEM: LATER,L ACING, RAVEL DE H BE PIPE
.
WIDTH: LENGTH NO.OF BED/TRENCH TRENCHES:
DIMENSIONS MA (FOLD ATEHIAL NO DI Tft DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
MANIFOLD DI R. IPE PIPES. CIA..
MANIFOLD PUMP .
ELEV.'. ELEV DIA E EV
ELEVATION AND VERTICAL LIFT CORRESPONDS TO APPROVED
COVER MATERI PLANS
DISTRIBUTION HOLE SIZE HOE SPACING DRILLED CORR CT DYES NO
INFORMATION ON PROPERTY WELL BUILDING:
❑Y S oes V TION WELLS NUMBER OF LINE
PERMANENT MARKERS: FEET FROM
COMMENTS: DYES O DYES O NEAREST
r
`~j•~/J~~- ' Ret n in county file for audit.
Sketch System on TITLE:
Reverse Side. TURE
DILHR SBD 6710 (R. 01/82)
wlsconsn APPLICATION FOR SANITARY PERMIT 1J
(DILHR
(PLB 67) COUNTY
oEaRRTmEnT
- fnOUSTRV,LRBOofR&HUMRnRELRTIons UNIFORM SANITARY PERMIT #
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
1VIV1 e 1 /
PROPERTY LOCATION
Ctfi't.
1/4 SO 1/4, S TN, R V4ELAGE:
(Of) W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK
STATE PLAN I.D. NUMBER 14
f1
TYPE OF BUILDING OR USE SERVED TE~J 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
❑ 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 Condition,_
Total # of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
l t~ C~ Private ❑ Joint ❑ Public
PName dersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
lumber (Print) Signature:
/MPRSW No.: PhoneNumber
Ad ress:L A7 ~
)<3"r~ti
Name of Designer:
f '.f , I-'Ly X~ i
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee:
Date:
❑ Disapproved
Owner Given Initial
Reason for Disapproval: Approved Adverse Determination
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.
f
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 ~Ya / cyt ~+3 /4z 60 "f j >C
LOCat- LOn of Property Section _5 T N - R ems; W
't'owns h _py-►tv
Mailing Address P 3 3
Subdivision Name
Lot Number
Previous Owner of Property 'A"- 2A-'j,,
Total Size of Parcel
Date Parcel was Created ~V v -7f
Are all corners and lot lines identifiable.? _ Yes - No
Is this property being developed for resale (spec house) ? Yes No
Volume 7eq and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of. Deeds Office
Tn 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
f'ROPERT y OWNER CE-RTIFICAT7N
T (GJe_) ee.n~tr,~y that aXX. 6tatement6 on .thy {onm ate ,tAue to the bmt oA my (om)
knowledge; that 1 (we) am (cute) the owneA(6) o~) the pnopmty de'sehi.bed in -th,i6
I n. onmat on 4onm, by vivT tue o{ a wa,~ltanty deed heconded in the 06jice o A ,the
County RegiAteh o~) Dee.d,5 " Document No. and that I (we)
p.7menV-y own the p~opoAed site {ion the. 6ewage o-- -6y/stem (o'r I (we) have-
obtained an eaze.ment, to n.un with the above dew cAibed pltopmty, Cott the
eorAthuctcon o{ paid syAte.m, and the. Game. ha/s been duty 'Leco.nded in the OA{) gee.
of .the. County RegiAten o{ "DeedA, az Doeume.nt No. ) .
2 j)
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNIFD DAP, STGNPD
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATI 'N:5 , SECTION: TOWNSHIP/,q~}TY: LOT NO.: BILK. NO.: SUBDIVISION NAME:
/a ~ /a /T-?./ N/R r!,F (or) W - A" u &
A; I/
COUNTY OWNER'S/BH~ NAME: MAILING ADDRESS:
:
USE f~ F Y /~I f^~ 1
DATES OBSERVATIONS MADE ,
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ~ ❑ New Replace
r~
• v:
Y
y
s1;lP ' IC TANK MA I N` F,NANCI AGREEMENT
0
S t . C ro i_x Count y
:Y
0 W N ou T
t~/! L r 1
0'_!'!'1~:/T30X NUMBER a( - fire Number C T'T: y/ S T ATE ~Yl [X I 'L I P
I
I
pr,Opr.lZ'ry ?,OCATrr~tiT:~- Section T 1 N, R
- - '
Town of St. Croix County, ~ii
vi-si_on = Lot number
~Z
a,
Improper use Ancl 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 1i_c_ensed septic t_ank_ 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 ma_y be eligible to receive a grant for
a maximum of 60Z 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 1-980, with the requirement that
owners of it-1 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 ver.-
lying that (1) the oa-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. o
I/WE, 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 Wi-;consin Depart- ~
ment of Natural Resources. Certification form must be completed
and returned to the It. Croix County Zoning Office within 30 days
o t!)e three vcar exni_rai i-on. (C(Iite.. ~I
S IGNEDW
DATE
St. Croix County Zoning Office
P.O. fBox 227
Ftammond, WI 54015
715-796-2239
Sign, date and return to above address.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
Dl!HR-SBD-6395 (R. 02/82) - OVER -
FOR, E s. ,3 Wadi.
tt,
` q= and (ies Yt ate.
Th,r, u, t a=' F ~ tit
N", e
F
s ,t . "aL i Ole=1. es ,3 ,a-, r 3.t.t, f=i.i - 1.
a.~.~ ~e a f ~ 41t .a Lam[ a.
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ZO A . • TIo
~ X5035 t~
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER r (jp r~~ J i~,~ ~y~ TOWNSHIP " SEC. T .Z:'.,'' N-R / W
ADDRESS ST. CROIX COUNTY, WISCONSIN
J i S.Su n (z r~ 1~7
SUBDIVISION 114 LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
c~,z I+ L,~ 1- ,
~Z in ~`V~✓IG~i L ~~,dv
T r~:~Lr~ Z
{
! r1 vac
YZ
COD
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: )ok-1-5 Liquid Capacity: ( Z
Number of rings used: Tank manhole cover elevation: SL
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0Side,~ Rear, o feet
From nearest property line Front, 0Side, 0Rear, 0 feet
Number of feet from: well /Il building:
(include this information of the above plot plan)( 2 reference dimensions ro ~r,ntic tank)
r
PUMP CHAMBER r
Manufacturer: Y" 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, 0 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: X~
Width: Length: v Number of Lines: 2 Area Built:
Fill depth to top of pipe: f' 1r9
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 boxes 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: 4
Dated. Plumber on job: 11))-aln/2 Q~t
m
License Number:
3/84:mj
)F'ARTM'ENT`OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. 60x'7969 PRIVATE SEWAGE SYSTEMS DIVISION
IUTADISON, WI 53707 BUREAU OF PLUMBING
)ff CONVENTIONAL ❑ALTERNATIVE r!!7~
Holding Tank ❑ In-Ground Pressure Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER:
INSPECTION DATE.
Roger Timm RR# 1 , Box 192, Wilson, WI ~
BENCH MARK (Pe rrnane nt reference point) DESCRIBE IF DIFFERENT FROM PLAN f Q a '/tom
REF. PT. ELEV.. CST REF. PT. EL
SE SW, Section 23, T28N-R15W, Town of Cady
Name of Plumber.
MP/MPRSW No. County Sanitary Permit Number
Dennis Rohl 3222 St. Croix 54971
SEPTIC TANK/HOLDING TANK:
MANUFACTUR ER.
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
BEDDING. VENT DIA.: VENT MATL. HIGH WATER
r I l DYES ❑NO DYES FIND
ALARM NUMBER OF ROAD. PROPERTY WELL: BUILDING I~. VENT TO FRESH
YES ❑NO FEET FROM LINE AIR LElr-
DYES ❑NO NEAREST f ~ / f~
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVEq
DYES ❑NO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMP ANO coNTROLS oPERAT oNAL D YES ❑ NO D YES ❑ NO
(DIFFERENCE BETWEEN NUMBER OF PROPERTY wELL BUILDING VENT TO FRESH
PUMP R AND OFF) FEET FROM L1 % AIR
DYES ❑NO NEAREST ?P "5
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing N/;711 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
CONVFNTIONALSYSTEM:
BED/TRENCH wIDT ' LENGTH No OF DISTR PIPE SPACING COVE
DIMENSIONS / THEN~s Q NSIUE DIA xPlrs
' NTf~7ERIA L: LIQUID
v I PIT DEPTH
GRAVEL DEPTH FILL DEPTH [>ISTR. PIPE v DISTR PIPE DISTR. PIPE MATERIAL. ISTR t
BE LOW PIPE. ABOV E.f+OVER. ELBy.INLE7 ELEV. END. NUMBER OF PROPERTY WELL. BUILDING. VE NTO
T FRESH
; ` '~-'I PY sJ. FEET FROM , uNE AIR IyL ET,.
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 make certain that it ON REVERSE SIDE. SHOW ELEVA-
DYES ❑ NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE '
PERMANENT MARKERS OBSERVATION WELLS
DEPTH OVER TRENCHBED DEPTH OVER TRENCHBEU DYES ❑NO DYES ❑NO
CENTER DEPTH OF TOPSOIL SODDED SEEDED
EDGES. MULCHED.
DYES ❑NO DYES ❑NO ❑
DYES NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES. FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV ELEV DIA ELEV PIPES DIA.
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING GRILLED CORRECTLY COVER MATERIAL
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on
Retain in county file for audit.
Reverse Side.
SI.C~yIATURE. TITLE:
..nf~'1 7 i
DILHR SBD 6710 (R.01/82) l / / ~
Rohl & Timm Excavating
KO ARCH STREET-HUDSON, WISCONSIN 54016
PHONE 386-8664
tr~ti c. h 5'z . vfs
I
L)
yv ;
r w"'K
Y~:~ ~ tom. 6r: 1_.Y ~i✓ iL-'~,..~'
E wig-consin APPLICATION FOR SANITARY PERMIT
DILr.HR dlt~ COUNTY
(PLB 67)
TEnT OF UNIFORM SANITARY PERMIT #
OEPRRT I nOUSTRV,LRBOR6 RumRn RELRTIOnS -,/9 / j
-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 OWN`E ' MAILINGLADD~RESS /
PROP R Y LOCATION CITY:
f VIL,LP, E:
-Se 1 $f~~I/4, s 3 , T2, N, R f (or) TOWN OF:
LOT NUMBER BLOCK UMBER SUBDIVISI N NAME NEAREST ROAD LAKE R LANDMARK STATE PLAN I.D. NUMBER
/
(r tr
TYPE OF BUILDING OR USE SERVED
X 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 ❑ 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 11/14
P
Manufacturer: ' t
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 V~IATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
1, 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:
w
012 t S E e0 t,-<i. C.- 3 Z'Z Z.~~ 1ST k:
Plumber's Address: Name of Designer:
~ , r z ~ ~ Wei. ~ `G f ~ "rr~
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Feg: Date: ❑ Disapproved
- Q / j/~/ ❑ Owner Given Initial
rliC~~t~ 9/ !3<~a 7 A 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.
O i,iL Z,r1rNEF,. ~~eos i~ i,t uv_? irvnnr!. Prnah .s,=. ~
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 PERMtT
STC - 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
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property "A
Location of Property --Lj section , T N - R W
-
Township /
Mailing Address
Z -77
Subdivision Name
Lot Number
Previous Owner of Property lc,d-o- `
Total Size of Parcel ~yc r_S- _
Data Parcel was Created
Are all corners and lot lines identifi;dble? Yes No
is this property being developed for resale (spec house) Yes No
Volume and Page Number 7 - 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 shalt also be required.
PROPERTY OWNER CERTIF=ICATION
I (We.) eent:6y that At statements on this 6onm ate thue to the best of my (out)
knowkedge; Aut I (we) am (ate) the owner (s) of the pnope)Lty desentbed in this
0 6onmati.on 4onm, by viAtue of a wahtanty deed neconded A the. Office of the
County Regi0et of Deeds as Document No. ~ ;;a'~jl~'~ and that I (we)
pneseatk-y owy the. p4opose.d site bon the sewage. d~posa2 system (on I (we.) Piave
obtained an Ec omumt, to nun with .the above de6co bed pnopenty, bon the
eortstAuetton of said system, and the same has been Wy AeLonded in the. 066,tiee
of the Count; RegAten of AM, as Document No,
St;N TURF 01 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
J6 J-)
DATE SIGNED DATE SIGNED
1