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O'CONNELL, JOHN NW NW,rSection 21
R. R. 3 T3JN 14'8W
I
New Richmond, WI Tq of Star Prairie
V\~rr
San.Permit#54988 9- Powers
Conventional, New
1
Parcel 038-1088-20-000 12/08/2006 12:12 PM
PAGE 1 OF 1
Alt. Parcel M 21.31.18.362C 038 - TOWN OF STAR PRAIRIE
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
JOHN A O'CONNELL O - O'CONNELL, JOHN A
1009 210TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 1009 210TH AVE
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE
SEC 21 T31N R1 8W 10.07A E 1/2 OF W 1/2 Block/Condo Bldg:
OF NW NW BEING CSM IN VOL III PAGE 814
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
21-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill M Fair Market Value: Assessed with:
175391 262,400
Valuations: Last Changed: 10/05/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 32,000 159,900 191,900 NO
PRODUCTIVE FORST LANDS G6 8.000 40,000 0 40,000 NO
Totals for 2006:
General Property 10.000 72,000 159,900 231,900
Woodland 0.000 0 0
Totals for 2005:
General Property 10.000 72,000 159,900 231,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 218
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
V
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
c ,
OWNER TOWNSHIP STcil d.~r, -k SEC. T _3j N-R~W
J
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 1LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
' n
i
,ass
26 /
r
5( G
i /
J'5 O
INDICA E NORTH ARROW
-on
BENCHMARK: Describe the vertical reference point used
f-
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: z "u
Z) Liquid Capacity:
Number of rings used:- Tank manhole cover elevation: %`C 7
Tank Inlet Elevation: C
/ t ~ Tank Outlet Elevation:
Number of feet from nearest Road: Front,a Side,
Rear, O feet
0
From nearest property line Front,QSide,0 Rear, O 1) feet
Number of feet from: well 'li`" building: 1 ,_y
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE 11
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, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: ?~f
Trench: 1
Width: / Length: Number of Lines: = Area Built:
Fill depth to top of pipe: 12
Number of feet from nearest property line: Front, O Side Rear, 01?t. S'
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.
I
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: y ~
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, 01 53707 BUREAU OF PLUMBING
LJ t.ONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If ass,gned)
r
NAME F PERMIT HOLDER: ADDRESS OF PERMIT HOLDER.
INSPECTION DATE.
John U' Connet 2 RR, New Richmond, WT ~ ~~_-~t~/
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
REF. PT. ELE V.: CST REF. PT. ELEV
NW NW Section 21, T31N-R18W, Town o~ StaA Pnai Lie
Name of Plumber. MP/MPRSW No.
Cou nly. Sanitary Permit Number:
Cat Power 1563 St. Cnoix 58882
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY: TANK INLET ELE V.. TANK OUTLE LEV WARNING LABEL LOCKING COVER
I ( YES ❑NO ❑'YE`S NO
BEDDING: VENT DIA.: VENT MATL. HIGH WATER
NUMBER OF ROAD'. PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM
FEET FROM LINE// / AIR INLET
YES NO ~ ❑YES ❑NO NEAREST ~ ~C" L- f~ /
DOSING CHAMBER:
MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMP ANDCONrROISOPERATIONAL ❑YES ❑NO ❑YES ❑NO
(DIFFERENCE BETWEEN NUMBER OF PROPERTY wELL BUILDING JVENTTOVRESH
FEET FROM LIVE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLIN(sTH 1111AMITIR 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 DIA #PITS LIQUID
DIMENSIONS TR~NCHES MATERIAL* PIT
DEPTH.
GRAVEL DEPTH
FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL . NO. Dl TR NUMBER OF
BE LOW PIPES ABOVE COVER ELEV iNLE r ELD yV. END PR OP ERTV WELL BUILDING. VIERNT TO FRESH
( 7 ` C ) PIPE- LINE
OM f~ A
I !•%1 L. L. I Z_ FEET FR INLET
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-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE
PERMANENT MARKERS OBSERVATION WELLS
n=7 DEPTH OVER TRENCHBED ❑YES ❑NO ❑YES NO
DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF EERA ING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD MANIFOLD MATERIAL N O. DIST
ELEVATION AND R ra~~ PIPE ELEVE L E VDIA. PIPES. DISTRIB UTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO ❑YES ❑NO
COMMENTS: r r PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF ~ROPERTY WELL. IBUILDING:
W's FEET FROM LINE'
❑ YES ❑ NO ❑YES ❑ NO NEAREST
i
~ 1 i
Sketch System on l
ount file for audit.
Reverse Side. v°y
SIGNATU TITLE
DILHR SBD 6710 (R. 01$2
wisconsin APPLICATION FOR SANITARY PERMIT
~ -~ILHR pig I~ COUNTY
a inou5T yLR[30R6HUTRngELFiTIOns ( 67) UNIFORM SANITARY PERMIT #
nOUSTRV,LRBO Yry
4
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/,x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILIN F~DDRESSy
PROPERTY LOCATION ~ IT VILLAGE'
•
1/ 1/4, f Uri , N, R 4 (or)''VV-1 OWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
r'
TYPE OF BUILDING OR USE SERVED
4 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): ~b
THIS PERMIT IS FOR A:
X 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.
1Z Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
El 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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Marl-
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
i
Manufacturer:
J/ u;•~
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):
0 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the pri e sewage system shown on the attached plans.
Nam7f Plumber (Print )~f / ESignat ` MP/MPRSW No.: Phone Number
6
Plumber's Address: Name of Designer: /
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Disapproved
"""'~v t ~L - ❑ Owner Given Initial
9i ~ 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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, cc DIVISION BOX HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCUTION: / SECTION OWNSHIP/RflUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNER'S/BUYER'S NAMMAILING ADDRESS: /
USE DATES OBSERVATIONS MADE
~ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
L.",IResidence I L:JNew ❑Replace ( I i _
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: IMPOUJ\I IN -GROUND-PRESSURE: a SYSTEM-I N'FILLHOLDING TANK: RECOMMENDEj SYSTEM: (optional)
rL SS U LLil- S S U ❑ S U
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:
44
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ICJ. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 4LA11- 01 a ` /
Ls TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCH S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI9D2 PERIO 3 ER INCH
P- 16 f 2
P-
P-
P-
E
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
y
X:- 140a: 1~Ca-c)
So,
. s
,
.
f
E ~ D 1
,
a
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedure 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 b lief.
NAME (print): TESTS WERE COMPLETED'ON:
AD SS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST NAT RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILIIR-SBD-6395 (R. 02/82) -OVER
~Fc" ps, n d yin;
2, ut,v -c ,I a, , ,
is W. _ wF i
`7
WHER SY PING ARE RU I-Ew --o", 1 it''
,"i_. EASE up? dip sb i .bkta , sho > ,f,f ."'PC 3 rt air-'. ,i, g]i-sv,ipn ,
5,~ . Cd t'. des[ ,
2, We nwe n., uy no ark and umlicul Wartiaq. &W onto Qv aw creaky shown, old we jowyn,n
y none :,mt.kfc } as S-it. U,t PUP , nw, i ,c>, tsDna _?;>t t?.
<e',
Iu:t :la 't U, ` '°V.xieti)tSa t,. t" rt..t ki ni , , t ;Nt a t
I w
s E;„ r! d i'ij- j I.r ':s Yt .}'aFS[s< L,. : S,S .sL .,r, i f :L'_{.F vv, €t}a
LOCAL JIM
ABBREWATRAS FUR _:?.R VIFTID SOIL TITTEFT-'~
i p 3-"' LS WwAoric,
4 Spin ~1 rl S(~} ~ ir3
4., !s ii iii, 3 Ht .c;y3' _
WMV Q& J Maw That
S t "3 r' y' W t >.s
r H n Rt
S w w-, 131 b . ~
W1.
SMMV C '
t
nm'ma vow
.
3€.[. 3 WK nw; .i , 9w, 400 'Cti a .i . .u. . F,. =3`'rp nA Icons s, i.hc 1 vary!
he p ,fix ve.... t~,.
f
PAGE OF
C c,
z
~ ) toss u n
it6j
Fresh Air Inielc And Observation Pipe
~r----- Approved Vent Cap
Minimum 12" Above
Flnul brode
42° Above Pipe _ 4 CaU Iron
To Flnol GraOa Vent pipe
Mar sn Hay Or Synhellc Covarlnq
win 2° Aggregale
Over Pipe
Oletrlbutlon
Pipe 0 0 0 0 0 ElCoopling To -
b" Aggregol•
Beneath Pip. 0 Perforated Pipe Below
0 Terminating AI
Bollom Of System
!Q"
SOIL FILL
DISTRij3UTiofl PIPE-
APPP.OVED S4NT TIC FOVEA
° ~"-MAT~RI~► OP y" 0P STRAW
2"0FA(,G9FGATE------' c OR/AARSN HAy
AGGREGATE o8
EL E V. OF FEES"
DIS~R1-1i I-ki PITT T(~ PE AT LEAST INCHES BELOW OR1C IUAL GRADE
A i ) I A' 1_EA°, O IP.II laV HI!1 F.I~ M.tP.4. -itlAhl t<' '~f`!CI~E f3r_LC,W FIt.-IAt GPAI P
MAXIMUM ®kQtH OF EXCAVATIDO FXom OW111VAL (JigADF- WILL BL tee: _ INCHES
MIN)MUM Wr)i OF CXCAVATIDW FROM 0~1G1aAL GRAPE WILL pE 'L INCHES
SIGNED:
LICENSE NUMBER:
110
Ji
- rt
~,2
1
+ II~, ' ,9 J i
.
i
I
ST. CROI X COUNTY
WI SC0 N S I N
ZONING OFFICE
_ 796-2239 (HAMMOND)
425-8363 (R I V E R F A L LS)
HAMMOND, WI 54015
October 23, 1984
Cano.tyn Haag
Bureau o6 Ptumbing
P. 0. Box 7969
Madison, Wl 53707
Deatc CoAotyn:
I have nesci.nded penm.it # 54988, and izzued #58882 to neptace it. The
system wic be placed ceos eA to the house than shown on the 6,c u t sex o6
ptaws. I was unab.te to obtain penm.it #54988. Ptease adjust youtc neconds
accondingt y.
Shooed you have any questionz, please contact this o 6 b.ice .
S-incene.ty,
Many J. enFz ims, SecAetany
St. Cuix County Zoning 066ice
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 79C19
PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, INi 53707 BUREAU OF PLUMBING
XI kCONVENTIONAL ❑ALTERNATIVE sHolding Tank ❑ In-Ground Pressure Mound NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER:
INSPECTION DATE.
John O'Connell R. R. 3 New Richmond, WI
BENCH MARK (Permanent reference points DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV. . CST REF. PT. ELE V.
NW NW, Section 21, T31N-R18W, Town of Star Prairie
Namc of Pl '-I'
MP/MPRSW No. County Sanitary Permit Number:
Cal Powers 1563 St. Croix 54988
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
eEDD:1N G: vENTDIa vENTMATL HIGH WATER DYES LINO DYES LINO
ALARM. NUMBER OF ROAD. PROPERTY WELL: BUILDING: VENT TO FRESH
FEET FROM LINE AIR INLET
ES LINO DYES LINO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
DYES LINO PROVIDED PROVIDED
GALLONS PER CYCLE: PUUMPANOCONrnoLSOPERAnoNAL LIVES LINO DYES LINO
(DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL BuILO Nc I VENT TO FRESH
FEET FROM NE AIR INLET
PUMP ON AND OFF) DYES FE
NN NEAREST
SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing IFN(,Tu 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 WIDTH LENGTH NO OF DISTR PIPE SPACING
COVER INSIDE DIA -PITS LIQUID
DIMENSIONS THEWHES MATERIAL: PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR
BELOW PIPES ABOVE COVER ELE V. INLET ELEV. END. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
PIPES FEET FROM LINE AIR INLET
NEAREST-►
MOUND SYSTEM:
Mound site plowed perpendicular to slope
and furrows thrown u Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
pslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
D YES LINO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE T ANENT MARKERS OBSEH VAT ION WELLS
DEPrHOVERrRENCHBED EYES LINO DYES LINO
DEPTH OVER ~TTRENCCHIED DEPTH OFTOPSOIL DDED [SEEDED JMULCHED
CENTER EDGES. SO
DYES LINO EYES DNO DYES 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 MATERIAT!7
DISTR. P
IPE ELEVATION AND ELEV. ELEV DIA ELEV. DIn:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORN ECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES LINO DYES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL. BUILDING:
NUMBER OF LINE.
i ❑ YES ❑ NO D YES ❑ NO NEARESTO-
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
DILHR SBD 6710 (R. 01/82)
s.
wisconsin APPLICATION FOR SANITARY PERMIT
COUNTY
~ DILHR
Zr_ oeaggrmenroF UNIFORM SANITARY PERMIT #
160USI' RV, LgROR 6 HUMP RELRTIOns
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP RTY OWNER r MAILIN~ ADDRESS
V
i
PR (PERTY I O,CA ON i- GJT_Y:
1/ 4 1/4, S N, R i~ u -LAGE:
(OY W.' TOWN OF:
LOT NU BER BLOCK NVIUMBER SUBDIVISIO NAME NEAREST ROAD, LAK~_OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: - ❑ Public (Specify):
THIS PERMIT IS FOR A:
L24 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.
--a
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 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):
r'
I/ 1/ 11 F~
2 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation o -e vate sewage system shown on the attached plans.
Na eof Plumber (Pri Sig tMP/MPRSW No.: Phone Numb
Plumbe 's Address:
/r/7> A / ~r Name of Designer: /
/ i r J/
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:: p ❑ Disapproved
e^ ~h ✓ Q 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
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 FOR SANITARY PERMIT
S T C - 1.00
This application farm is to he completed 1" 'u1! ud 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 iq 1`% t~ ~.~A%fuLLL- _ _ Location of Property Section 2, T "3 N - R W
Z' L
Township T A, PA7,q
Mailing Address ffL'r,'iF 1
Subdivision Name
Lot Number_ Z%41=
Previous Owner of Property
Total Size of Parcel Yc?t
Date Parcel was Created 01t -F 1 /5
Are all corners and lot lines identifiable? Yes No
1s this property being developed for resale (spec house) ? Yes No
Volume and Page Number 0141 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLTCATI-ON ONE. OF THE FOLLOWING:
Warranty Deed
i
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
T (we) eentQy that aTf statements on this 4otm ate tnue to the best of my WA)
Nowkedge; that I (we) am (ate) the owner (o) oA the ptopeaty demnibed in this
Quamation. Aotm, by virtue of a wahAaN y deed seconded in the 06lice o{1 the,
County Rego seen oA Deeds as Document No. -3, ; all ; and that I (we)
,y)'ieAantty own the, ptopohe.d site {got the sewage dispGal system (on 1 (we.) have
obtained an easement, to tun with the above deAenibed ptopenty, {got the
consthuclion o4 said system, and the same has been duty necotded A the O(Ai-ce
oA the County Regi6tet ol Deeds, as Document No.
SNh OWNTKSIGNATURE OF CO-OWNER (IF APPLICABLE,)
DATE, SICNI'D DATE: SIGNED
H
' C!1
S T C - 105 r
y
H
SEPTIC TANK MAIN'T'ENANCE AGREEMENT 0
St. Croix County z
0
9
OWNER/BUYER / 412I'1f'/~ti Pv ra
ROU'T'E/BOX NUMBER ~,'j / Fire Number
CITY/SPATE St-7 CC.L Z11)
i
PROPERTY LOCATION: ~4, Section T R
Town of St. Croix County,
Subdivision Lot number
I
Improper use dnd 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 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 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- bite 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
F
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- lu
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 d'ate.
SIGNED
D ATE
St. Croix County Zoning Office
P.O. Box 98-
Hammond, W1. 54015
715-796-22"9 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) MADISP.O. BOX ON WI 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: u W TOWNSHIP/MUNW4PA-LITY: LOT7-IBIL . 1. SUBDIVISI NAME:
i '/4;,,) '/4 N/R/'~ lorl n J'
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: CDESCRIPTION: r~ PROFILE DESCRIPTIOS: PERCOLATION TESTS:
ResidencP
IDINevv ❑Re lace RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: -GROUND-PRESSUR7YSTEM-IN-FILCH LDING T NK: RECOMMENDED SYSTEM:( ptional)
[XIS ❑U OS ❑UIN
[ZS [:]U ❑S ❑U ❑S ❑DU 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: i
DLL PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH W, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / -
_ CIS
5-3 7
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER lNel-t€S AFTERSWELLING INTERVAL-MIN. PER10 t _ PERIO 2 PERT D3 PERINCH
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. /I)
SYSTEM ELEVATION'
3
3
t
'Sel
TI
-
-
f N
X
a
E
E
~ ) t f iJLi z -
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:
!
ADDR S: /f CERTIFICATION ER: PHONE NUMBER (optional):
r
• C IG TU E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DII._HR-SBD-6395 (R. 02/82) - OVER -
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PAGE OF
r ~ ~Cro S z c► o r1 p U r i~ J S n-~
FfGlh Air Inlets And Obeervallon Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade
20 42" Above Pips -4" Cost Iron
To Final Grade Vent Pipe
Marsh Hoy Or Syn Metlc Cover lnQ -
Mln 2" Aggregole
Over Pipe
Dlelrlbutlon
Pipe 0 0 0 0 0 - Tee -
AggreQate
Beneath Plp• ° Perlorated Pipe Below
o Covpling Terminating At
Bottom Of System
~~tJn f ion
SOIL FILL
DISTRIBUTIO►.I PIPE
APPROVED S41ITH[TIC COVEP
MATERIAX OR 9" OF SRAW
2"oFg6GRE4 AlE OR MARSU T
HAS
OF 1/? 21/z AGGREGATE
ELEV OF22 fEET~
DISTRiRUTIc~1J PIFE TO BE AT LEAST i1J HE5 BELOW ORICIIJAL\GRADE
AIJL AT LEAST20 IUCHES BUT 1.10 MORE THA)J 2 INCHES BELOW ~ t1AL` GRADE
R I
l;
MAXIMUM WTH OF EXCAVATI00 FX01`1 vKi& L (3KA~ WILL BIL IAJCHES
MIKIMUM OCT" of FACAVATlow FROM il*161 L a~ WILL HE _ I"CHEs
J
S16►.JED: ~
LICEIJ5E AJUMBER:
DATE: ~ - Lv
tto
CIL
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