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AS BU1 LT 5AN 11 :111' Y; FILM. I<i.i0)K_T
4 T _
OWNER TOWN51i1Y y SEC. 1 N It W
ADDRESS of ST. (:I:i)1 X COUNTY, W I SCCINS I N
SUBDIVIS ON l.u'I' ~ I.OT :;ILE
P IAN V I I-M
Distan<:us and dimernsions to mutt rc'yoil(~lll ,utr, of 11 6)
SHOW EVERYTHING WI.TH1.N 100 F1,11"T OF SYSTEM
f
I
A/ f
I
i
I INDICA'I'N NORTH Akl,()W
BENCHMARK; Describe the ver[ica.l rul urunc e. po i.nt use-d
Elevation of vertical nAerence point. 1) ropo.s slujw at s te: Qc
,
SEPTIC TAN1'.: Manufacturer: 1,iquid C.lpxlcit y: 45:>P?h
Number of riul;r., used: I'~iulc m;mhol, ~ ,vr t,Ic.v:11 iou:
'l'ank ILJt.t Elevation: Tank OutlL't t?lcv~~tiun:
Number of teet from nearest Ru<.4d: Front-,0"';id~oRuar, (D (`r ~ Ic~'l
r
I~CUIiI Cll'Llrl'Sl i~l'1~p1.:Yt~! 11.111..` I''Iolll ,O'ili~~~,OI~~'.ll ,O ! lii'l
Number of iuet from: well buildinf;:
(lncludu this Inturmatiutl of
the above plot plan)( relcrunce diuurn:;iillr:; to scptir
Form - S T 104
AS BUILT SANITARY SYSTEM xLroRT
OWNER TOWNSHIP SEC. T N-R W
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
i
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:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,0 Rear, O feet
from nearest property line Front,0 Side,0 Rear, 0 feet
Number of feet from: well building:
(Include this information of the above plot plan)( Z reference dimensions to septic tank)
SET? REVFI:SF: S I I)F
A -
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: 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, Ft.
Number of feet from well:
Number of feet from building:
(include distances on plot plan).
SOIL ABSOR PrION 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 fiet 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 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,
LABOR & HUMAN RE LATIONS INSPECTION REPORT FOR
SAFETY & BUILDINGS
P.O. BOX 79Q6 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
5&ONVENTIONAL El ALTERNATIVE State Plan I D. Numbe,
❑ Holding Tank ❑ In-Ground Pressure O Mound IIf a-gned)
NAME OF PERMIT HOLDER:
ADDRESS OF PERMIT HOLDER.
INSPECTIO DATE.
Robert W. Taylor R. R.3, Box 325, Hudson, WI 54016 ` Y --/o AM
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV.: CST REF. PT. ELE V.
NE NE, Sec.4, T28N-R19W, Twn.of Troy, Lot#4, High Ridge Court
Name of Plumber:
MP/MPRSW No.. Cnu nty. Sanitary Permit Number:
Paul Cudd 2739 St. Croix 49505
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDE O: PROVIDED:
BEDDING vENrDIA. vENTMATL H ;Hw ER O
YES ONO OYES ONO
LARM NU ER OF ROAD: PROPERTY WELL BUILDING OYES ONO ' F FROM LINE
JVENTTOFRESI,
AIRINLET
NO REST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY `PUMP MODEL
PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
OYES ONO PROVIDED PROVIDED.
GALLONS PER CYCLE: OYES ONO OYES ONO
PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN LINE (AIR INLET
PUMP ON AND OFF) ❑ YES FEET FROM
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NO NEAREST DIAMETER MATERIAL AND MARKING,
or excavation. (If soil can be rolled into a wire, construction shall cease until L FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH
\ LENGTH TRENC DISTR. PIPE SPACING COVER
TRENCHES INSIDE DIA -PITS LIQUID
DIMENSIONS MAfT~RIAL: PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTR. PIP'F DISTR. PIPE DISTR. PIPE MATERIAL. NO. DIST H.
BE LOW PIPES ABOVECOVER ELEV. INLET EL4V E PIPE NUMBER OF PR OE ERTY WELL. BUILDING: VENT TO FRESH
y 2 7 Z 41 FEET FROM 4~T
, S V v'~ ~ ~ ♦~r AIR~NLETw..
NEAREST--s fip
MOUN YSTEM:
Mound site plowed perpendicular to slope
ope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown rpl
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
EYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER rExruRE
PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED OYES ONO OYES ONO
CENTER EDGES. DEPTH OF TOPSOIL SODDED SEEDED
MULCHED.
OYES ❑N'O EYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PA F
TRENCHES: FILL DEPTH ABOVE COVER.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MAN IF LD MATERIAL.. 0. DISTR. DISTR P, E DISIMBU TION PIPE MATERIAL & MARKING
ELEVATION AND ELEV ELEV CIA ELEV. PIPES DIA:
DISTRIBUI ION l
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLv
COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
COMMENTS: PERMANENTMARKERS~YES ONO OYES ONO
OBSERVATION WELLS: :TNEUEUMBERR OF PROPERTY WELL: BUILDING.
T FROM INE
OYES ONO OYES ONO EAREST
0
CV
is L`{ .6
1f I v
Sketch System on L
1
Reverse Side. Retain in county file for audit.
` SIGNATUR TITLE -
ILHR SBD 6710 (R. 01/82)
DEPARTMENT OF APPLICATION
SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN REL,4TIONS (PL13 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Proper Owner:
7Mailin Address:
2'~
Property Location: o~ City, Village or Township: Co nty:
IV f%'/a r/4S iTu~ iR f(or) W ~._y-ems
Lot Numb r: Blk No.: Subdivision Name: Nearest R ad or andmark: State Plan I.D. Number:
J` (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)%V_ ~ Bedrooms:
❑ 1 or$Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minn es per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental ( Seepage Bed ❑ Seepage Pit
rq ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the dersigned, hereby assume responsibility for install of the private sewage system shown on the attached plans.
me Plumb Signat re: #P/MPRSW No.: Phone Number:
Um er' d ress: Name of Designe
r
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Date: YAPPROVED Sanitary Permit Number:
r pv` I~
l0 '~1' ❑ DISAPPROVED
~eason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03/81)
APP1,1CA'!'10N !,'01Z SANITARY Pl,:!LMIT
S T C - 100
This applicati_oli form is to be completed in I - u11 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 Q . E~ T' W
Location of Property k) _4 )V7`4, Section, T ~ N - R W
Township
Mailing Address
Subdivision Name ~A, ~ 1ZxVE c_n
Lot Number _ !A•
Previous Owner- of Property Ai ~,A)J L
Total Size of Parcel Z !"w~Q-~...5
Date Parcel was Created I~Jg7G
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volumeand Page Number as recorded with the Register of Deeds
T NCLUDI? WTTII TI-11S) APP!. I CAS' I ON 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 shall also be required.
PROPERTY OWNER CERTIFICATION
I (CUB) ccA if y that Of 6tate.ment1 on .this ~onm ane tAue to the beAt o~) my (o«tc)
know-Cedge; that I (we) am (aw) the owners (s) o{ the, property deg n bed in thi,6
In4oronati,on Aonm, by v-v_tue oo a wcmanty deed neconded in the OA4ice_ o4 the
County Re_giAteA oA Dee.&~ cus Document No. 14, 6-97 ; and that I (we)
preerse.vut('y own the pn-oposed site. ,ion the. s ewagd z pow. A y'S te.m (on I (we) have,
obtained an easeme-nt, to nun. with. the, above deAe,7.ibed pnopeAty, {,on ,the-
eow5.tAuetion o{ 6aid s ys,tem, and the, same. h" been du.Ly ne.eonded .in the. O~()ice
oA the County Registers o{ Deeds, DocumeY;0', No. 7M) .
A . Z
af W~ Z; e d0:: - - -
r &07
S GNATURE OF OWNER SIG.ATURE OF CO-OWNER (IF APPLICABLE.)
rl? SIGNED D F. SIGNED
c T C - 105
y
SEPTIC 'PANE. MAINTENANCE ACREEMENT
0
St. Croix. County
o
OWNER/BUYER
ROUTE/DOX NUMBER <<_ ~ Fire Number
-Z~ 41
CITY/STATE L ill
1
PkC,PEKTY LOCATI0NA1i1b, lil '4> Secticu 1' ~N, R~~
Town of _ ~ tta~ St Croix County,
of number
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 Lumper. 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 recuivu a grant fur
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 Su'L)Ill it to St. CroiX Cuunty ~onin~' a
certification form, signed by the owner acrd by a master pluulber,
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
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 Wisconsin Depart- ~o
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three yuar expiration, date.
SIGN U
D ATE s
ti
St. Croix Cuunty Zon-ng Office
P.O. 1.ox 98
If amnroi d, W1 54015
715-7~ 6-22311 or 715-425-8363
Sign, date and rc,turn to above address
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
HU
MAN RELATIONS PERCOLATION TESTS (115) MADISOP.O. BOX 76
M
N WI 3707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/"""ir- i ini;~,-°^L--Y: LOT NO.: BLK. NO.: SUBDIVISION NAME:
1/4 1/4
COUNTY: OWNER'S/BAR=S NAME: MAILING ADDRESS:
EZlLT- -F?C~ YLC) a
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
~~Residence ❑New [Replace -7_
71
RATING: S= Site suitable for system U= Site unsuitable for system
CO~ENTIO❑NAL: MOUND: Sf-~ IN G®~ P❑~ RE: SYSTEM-IN-FILL HO❑LDING~XT~A,NK: RECOMMENDED SYSTEM: (optional)
SS UU ~ JS'® S QU S (`1\ ~•J V'
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the N
under s.H63.09(5)(b), indicate: f I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-iii tES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH V ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
tS 3._7 71 S
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER Ihlf_ FMS AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ s -Z
P_ Lz
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 s '
\,C~.Q~' 1.5, bF SWei~
C:~ IF - J_~ 5 Icy
I
'rop of VEhIT PIPE'
100.00
. yp ~IF\ I 0 ) lJ
FZ'~i G✓ I ~(L/ j~y IST IN fa Q
cl
8'l I
to
•k
v- pz . L,
s
sl
°vo
F ca
E
E
1, 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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) - OVER
Was P ms Ds hl W-zL'Lt N ! a ma An IL u,.
FCC h 3 =.,3mt,A y a rd ssn_~
Co 05U A W:
o, IM AXi:N Letts ..r e`r of bbd =iris Gr c.... ia4 ; .
- ~S lz e rfu {;s ,Cr:9il1E=)}~' .,~'St~'1=~'.`
Pt EASE me We aWr AaA s 9(J.*. t8 y" for wrE inn
MAKE A !.EGAILE d sp a. iSGC'.?,s.ltdv 1a „_a:;tl y tlm" so Wi•< nv Da yang in ~'£^,t 4 prp rY_ L
i, " z u gaE; 0, £,'P . . , v, L F, air„r ss t„1=, cc Nome ? f-1[i':, are J2 O...
,ii iapl,-cci _"iat _.a sss ra 'let nh-= 1, , ailC➢lc 1mm
€L,cr_. °o is~'rx t sUr3:NI 00n, s..L., e.t,=y21 t,.3e5 Pif.3 <i (nAye 1dx3 G.i
~',L.""i ai,a, curie nt "di-14 , and' yout corn
smqw won 10"', SR No
Cubma 13 l~e'' SS s m
- s er", PICAV - P+,3t t,~_•
Coast ` aiicl P a pal
L s y S;A ,,E - ch e .
L.. i w-
d Wool Sr 3
y
Si,:-e Clay l?~,; o tF
SWAY y
Clay
, aE ti! re..
,3 nct
ia4 € s€)J lea < I Via ?f ,r so, l_s Pam im o-. A i ,:Y?pka, mi of P!ms for BE Pinto
I
P A C L)l
~VJN C~~~ '1Jh NG
CROSS SECTIDU OF A B=
t
VE,FJT TJ1 PE
~iIJ\Sl1~O C>TZAbe
2 OF AGGREGATE
.4 SOIL FILL ;
F_'_~, r n P C
Ll Y:N BllT1DU PIPE APPROVED Sy1JTHETIC COVER
DISTR) 4 lAATER1AL OR 9" OF STRAW
o
C )F, MARSH HAy
Jo' OF1/2, AGGRF-GATE
ELEV. OF FEET
- ~E•R~orZATED P1P~ To
~`I-1-pM Or B f=Q
Z 0JC.HE5 BELC)- ORIGII.IAL GRADE
DISTRIBUTIOU PIPE TU BE AT LEAST
A►JD AT LEAST ZO IiJCHES BUT }JO MORE THAN `i2 11JCHCS B= ~-OW FMAL GRADE
-70 I►JC- HE5
`
MAX1Ml1r~ DEPTH OF ~XCAVATIOF] FROM ORIGINAL GRADE \.JILL BE
INCHES
I'U►JIMUM DEPTH OF EXCAVATIOU FROM ORIGINAL GRADE WILL BE
- j
SIGTJED_ _
L IC, E IJ SE UUMBE R:
n T r
San. Perm:
H6 .05 PLOT PLl
Show:
LA Location of building served posinc chamber
Q Septick tank Vertical reference poil:t
Buildirxj sewer Horizontal reference poi.:--
Effluent system IA Well
Peplacement system area N;R Prop°~-ty lines w/in 50' of system
( } Scale or dimensioned
Di stributior. boxes .A Pimp and controls:
r-fr. & M7odel No. Vertical Lift Size Force rain
- p
Fri cti o:i Loss T. D, H. Vol. Dist. Pipe Gal. per 1 ~n. Gal. per Cycle
Place check mark in appropriate box, indicating item is shown on plot plan below:
~`GJC4{ '~~;2p: -
T
4xtST Z S ~~ovE
~3 ~ 6 Is e~~ -~uh I
to i
?_'vG LlOJ ~ TU
CtST.
By the granting or approving of the above plan, or upon the event of a subsequent
permit being issued, ~---Fuolx County and the STCFOIX County Zoning Administrator, does
not assume or hold itself liable for any detects in ,plans or specifications, plan
omission, examination oversight, construction, or any da that may
turesult in or
after installation.
Plumber's signare