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♦ Fo rut - S '1' C:
AS BU'IL'T' SANITARY SYS'T'EM REPORT
1 TOWNSHIP T~+~``41 Y SEC. T 19 W,.,
OWNER '
3 /3 0)C ST. CROIX COUNTY, WISCONSIN
ADDRESS .
SUBDIVISION' Hr' A h ,'J"_t Coc rT LOT LOT SIZE ct h,
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
!0'
u
G' vent
Nv `
i +n S t
- 4w
,r r}u t5~~ r" ~
IND'TCATE NORTH A1tROW
SC0.1~ I„ qU,
BENCH 1M; Describe the vext.ical reference point used ory, (u
fl~ r~L 4IJ~
Elevation of vertical reference point: Proposed slope at site: Z I
SEPTIC TANK.: Manufacturer: Lt- / e Pr;" r Liquid Capacity: I V OG'T
Number of rings weed: 'l'ank manhole cover elevation:
Tank Inlet Elevation: A , Tank Outlet Elevation: ~ 0
Number of feet from nearest Road: Front,0 Side,(aRear, a feet
4 From nearest property line Front,QSide,ORear,~ feet
Number of feet from. well building: ;
'
plot plan) 2 reference imensions to septic tan
~
,ference d
o f the above cl.de this information
(gin u
PUMP CHAMBER.
Manufacturer: Liquid Capacity: M_
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, F't._
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSOR'PPION SYSTEM
Bad. ! 'X 1 Trench:
Width:' f Length: 7,0/ Number of Lines: 5 Area Built: «0
Fill depth to top of pipe: Q,2 (42 „
Number of feet from nearest property line: Front,' (~Kide,~ Rear,O Ft.
Number of feet from welly
Number of feet from building:
r
(Include distances on plot plan).
SE P4dt PIT
Size Number of pits: Diameter:
Liquid depth;, Bottom of seepage pit elevation:
Area Built:
~i
Has either a drop box y or distribution box(&/ been used on any of the above soil
! 1l . V,,° 4- Wyam'
abear#~tion >ayrems? (heck one). \L,/ i ile Vet L
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, Ft.
Number 1
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm ranufacturer:
Inspector:
Dated: Plumber on job: '
License Number: 4
t4
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 ♦ BUREAU OF PLUMBING
MADISON, W' 5:707 w '
State Plan I.D. Number.
IWONVENTIONAL ❑ALTERNATIVE
(If asslg ned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. :::JDDRESS OF PERMIT HOLDER: INSPECTION DATE.
Ronaed J. Mon . R. 3, Box 331, Hudson, W1 54016 I~ - '?.°Od
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PT. ELEV.
NE NE Section 4,T28N-R19W Lot#16,High Ridge Ct., Town of Tnoy
Name of Plumber. MP/MPRSW No.. County Sanitary Permit Number.
Pact Cudd 2739 St. Cnoix 54906
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED
V L 0 DYES ENO DYES ENO
BEDDING. VENT DIA.. V T MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH
ALAR FEET FROM LINE AIR INLET
DYES ENO f ES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER 7ING
L
I UID CAPACITY PUMP MODEL PUMP'SIPHON MANUFACTHREH WARNING LABEL LOCKING COVER
PROVIDEDPROVIDE trES ENO DYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPEHTV WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR wLEr
PUMP ON AND OFF) DYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ni uIAMETEH MATERIAL AND MARKING
or excavation. W soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER/// INSIDE CIA. =PITS LIQUID
_7 I
BED/TRENCH / TRENCHES MA RAAL PIT DEPTH
DIMENSIONS
GRAVEL DFPTH FILL DEPTH DtSTH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
1 LINE AIR IT
BF LOW PIPES ABOVE COVER EL ~L. IN f r ELEV END. 7 PIPES FEET FROM
-t 2, f 3" 3 S 2 7 2 7 NEAREST-- ► f ~~of 'SO~
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. TIONS MEASURED.
DYES ENO
SOIL COVER TEXTURE PERMANENT MARKERS JOWELLS
DYES ❑ O ❑ ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH, BED DEPTH OF TOPSOIL SODDED 111EDMY MULCHED _
CENTER EDGES
DYES ENO ❑ YES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL EPTH BO VE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. TR. PIP ISTRIBUTI N PIPE MATERIAL & MARKING
ELEV. ELEV.. CIA. ELEV.. PIPES A..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICA IFT CORRESPONDS TO APPROVED
PLANS
EYES N a) DYES NO
COMMENTS: PERMANENT MARKERS BSE vnnoN wELLS. { NUMBER OF PROPERTY WELL. 77NG.
FEET FROM LINE
! OYES ENO EYES NO NEAREST
c,e,e ~cQv~ wed o~~Q~ D J0
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNA / TITLE
DILHR SBD 6710 (R. 01/82) - " ~
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND, PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% 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.
Property Owner: Mailing Address:
Ronald J. Olson Rt. 3 Box 331, Hudson W 54016
Property Location: gkWy R Township: County:
NE '/a NE'/aS 4 / T 2 8 N / R 19 )FxW_rj W Troy St. Croix
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
16 High Ridge Court Hi h Ridge Road (If assigned)
TYPE OF BUILDING
Public* ❑ Variance* ❑ Other (specify)* Number of
❑ ~ie1 . (}~D~~_ Bedrooms:
1 or 2 Family *State Approval Required. 4
I
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: Weiser
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New Xn Replacement ❑ Experimental 51 Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Class 2 1245
Water Supply: Listed on Soil Test Report (If other than present owner):
ER Private ❑ Joint ❑ Public M7 as
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signat e: .
MP/MPRSW No.: Phone Number:
115 11 ) -2049
Paul R. Cudd ' 2739
Plumber's Address: N e of Designer:
Rt. 5, Box 364, River Falls, WI 54022 Arthur L. We erer (576)
COUNTY/ DEPARTMENT USE ONLY
gnat a of Issuing Age Fee: Date: APPROVED Sanitary Permit Number:
pn&e Cec~ ❑ DISAPPROVED j
Reason for Disapproval:
Alternate course(s) of Action Available:
i
I
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to r-
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)
Vur-w - S T C IOU
.b
Owner of Property_ 2% Id _G a, '--C ISv~
.Location of Property k3t ~ O(E=4, SCCtiun__~__ N It-_/_9_W
Township` T(Qa V
Mailing Address ~r 3+ [ja 331
S u b d i v i s i o n N a w e
Lot Number
-
Previouu Owner of Property ~cigp '~QbS ~T2c.c~•rryw~
Tutal Size of Parcel,-- ~C~C~
Date Parcel w4a CreULed
Are all corners identifiable? Yes No
InClUde with .[:Ill L, a))ll1, ton one o1 Lhu tullowiIl.Certitied Survey Map
.Deed
.Land CUntraCt, or
Other Leal DOLUUlelit which deaCrlbus Lite property
-
PROPERTY OWNER CERTIFICATION
(We) certify that all statamants on this form are true to the bast of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Ragister of Deeds as Document No. 3g $ 3 Z~ ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an patiumant, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Oftiea
of the County Register of Deeds, as Documant No.
SIGI/NATURE O WN SIGNATURE of CO-OWNER (IF APPLICABLE)
c~%E/I~q _ _
GATE SIGNEp DATE SIGNEO
Form No. 105
s,
y
r~
_ r
SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County
d
y
OWNER/BUYER
ROUT1:/L,OX NIJM~',F?R ~ Fire Number
__~5.!2:~-cam
CITY/STATJ? ZIP
-
PROP11ITY T,OCA`'ION.~-~ '`'DIY L~~Jr,~ Secrion T a _N, RW
I
Town of St. Croix County,
Sti}>di.v:i-s.io t number
I
Improper use rind 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,
i_f 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 n_ew systems_ ati,,ree 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. CD
J/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-IT~
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Off' Ye withi Ways
of the three year expiration date. ~~kd/137,
I
SIGNED
G
DATE C~TyC
I
St. Croix County Zoning Office
P.O. l3ox 227
Hammond, WI 54015
715-796-2239
Si_,.>n, ?rarc ; nrl return to above t,ddress.
DE'PARTMENTOF 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: TOWNSHIP/MUNIGI-P-A-L+TY: LOT NO.: BILK. NO.: SUBDIVISION NAME:
~/a '/a
COUNTY: OWNER'S/BU~S NAME: MAILING ADDRESS: F/i lc/(,7s
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence Ll 1 ❑New Replace v_
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
LS ❑U ❑S ZU DS ❑U E DU ❑S QU
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-IN##€S 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- L/' 7Z
13- S.1-1
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PERINCH
P-
P-
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.
SYSTEM ELEVATION "t)TT
'EiC2~ 5' v~,o_+ . ~~JS~,~ ~'1 .~~.•vc. ~'L dU 2rhJ ~ J~ _
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t is form were made by me in accord with the procedures and methods specified in the Wisconsin
I, the undersigned, hereby certify that the soil tests reported o /I
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.
DILHR-SBD-6395 (R. 02/82) - OVER
A= fit
-01 and Oxman soil You; ~Lpco't n-,ust ;nciude~
i US., k, t,I.''ct o ;r.,ti YJ"Ct ar ? 0 4 : C s?C. .1C;L t7t ca-e- ei 3C t~} &iCi~e Cr;
INIA ,a 'P_aa wnr)er (if f:)£,d cii °"t1 UY couline planned;
is this a n t"E'P(-?f'i'.P`? MI, syStE'(n;
C;=: mtal<ve kre, -;iwt> liq rating FE . A .7 F T X ETAbl-C, F,'-- 6 A HOLDING TANK ONLY IF ALL
M }-$ER SYS: E 1"+16 RE i L)LEID COU T BASE D N" SOIL Ft ~Di'-C0 NS;
h=r!, A, f_E ciitii cliagrar`t k wa. og YC,}£,i;. !o """Cal o E., pi£'tot u(J- A
,f$i n `7enc ..:c€i and b _s,..,c. .,,a3 t,i„.},. h.,., ra}in 3' U Pac,.r£. v ch€, _JPP, ,;T£$ GFL' iJ E3., 1'; idl',Ee.
's..P:. t~.n '-d, _,7%;.3ioje- <ie hoo o,S as 'tc damn nwm MJP 4 eS, ne,,0 plain don, ;5 6,:LMon test C' ;>_',YYtp,
soon 11 a0lournimn;
if , n° orm f_„ n d n from! plain, a€ a, n) € oon nM ;r? w on, TA _ in w ad's,. s, iwn haa;
nm ME „a. r i and (3due " "',o .P can 'Piz adfjtt dl your Sown on, 141 BR BY,
Mow (3. 121 S Soh,
- rav ! iuroIk,i - ti
5
_ St3e't~ ~G~U F`i iE' G
i ,a .e ant. Pew air`„
[ "
P me swtl BM
Loony Soo! ~ - GM",
Sot „t
My Lown
iy C ' ref 3...om-t Cl~,
t
SON _ y Ln= M01
Sol GO"-' on
. .
P,1'a
Mgt
it P b, E 3 i _s t"
.a .z eY', ie, , a ,r z". rf r"t; ~ ,_l o-6.-'
CROSS SECTIDU OF A= S~ST>=/'~
- f
~IIJ~SH~o GtzH'o~.
AGGREGATE
?"OF
SOIL F-ILL
Ll j N C
DISTRIBIJTIOQ PIPE APPROVED SyWTHETIC COVER
/'thTERiAL OR 9OF STRAW
OR MARSH HAS i
(o pF%Z-2~/Z AGGR~GAT~
ELEV_ OF ^`a• FEET
- nE~z.Fo~.A'rEn P~P~ To
x`1""1-pM ~F BE1~
I►JCHES BELOW-f ORIGI►JAL GRADE
DISTRIBllTIoQ PIPE TO HE Al LEAST "LOW FIi1AL GRADE
A"D AT LEASTZO IIJCHES BUT MO MORE THA►J `~2 IUCNES B=
71
-7
I►JCHES
mt,xitAUN DEPTH pF LXCAVATIOIJ FROM ORIGt►JAL GRADE t-JILL BL 3S INCHES `
MINIMUM DEPTH OF EXCAVATIOU FROM ORIGIUAL GRADE WILL BE
SIC-"ED, A e-4~~-
L IG E ~ SE UUMBE R=
• - - San. Permit No.
C;an ' s name
H63.05 PLOT PLAN
Show:
F 1 Location of building served Dosing chamber
Septic tank Vertical reference point
Q Building sewer Horizontal reference point
1 "R Effluent system Q well
N Replacement system area F Propert,, lines w/in 50' of system
Distribution boxes ( Scale = 111 = , or dimensioned
IEY Pump and controls: _ ( - -
Mfr. & Model No. Vertical Limit Size Force Main
Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Miss. Gal. per Cycle
Place check mark in appropriate box, indicating item is shc-,7n on plot plan below:
-
~NRP - S 9f.1
A,
BI
7
7 -3
ESC! jT. r O ~ I ~ -
,±gl
1 IA
7
CyS~- ~xtST.
i
By the granting or approving of the above plan, or upon th- event of a subsequent
permit being issued, - -F'-o}x County and the STcRojx County Zoning Administrator, does
not assume or hold itself liable for any detects in plans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
after installation. -A~■~►C
Plumber's signa ure
San. Pe Fit Nc.
u H63.05 PLOT PLAN
Show:
[A 1 Location of building served NA Dosing chamber
Q Septic tank Vertical reference point
Building sewer Q Horizontal reference point
Effluent system Well
vA Replacement system area Propert-y lines w/in 50' of system
C~ '
VI Distribution boxes ~ Scale = 111 = 4 ;J , or dimensioned
Pump and Controls:
Mffr. Model No. Vertical Lift Size Force Main
Friction Less T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle
Place check mark in appropriate box, indicating item is shc«m on plot plan below:
~?CiP S gl -
\grlo ~HPVC b_O ~T
- - - - - - -
Y i ; y;
-1 r I ,
V0
gcpZl~ i'?~iJ'r,
I,
UJ
By the granting or approving of the above plan, or upon the event of a subsequent
permit being issued, , S-Roix County and the nT.cF1o1X County Zoning Administrator, does
not assume or hold itself liable for any defects in Tlans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
after installation.
/a
Plumber's si nature
146 3 . o L T LuD P
-,,,cation of building served Dosing chamber
Septic tank Vertical- reference point
ff ✓ Building sewer Horizontal reference point
well
Effluent system
Property lines w/in 50' of system
Replacement system area -
} j Scale or dimensioned
{ 1 t Dl- stri buti on boxes ! L -
(N J Pump and Controls:
Mfr. & Model No. Vertical I-_ ft Size Force Vain
-
~_------N; -
. Gal. per Cycle
Vol. Dist. Pipe Ga=•_pe- Y
Fri co on Loss T. D. H. .
Place check mark in appropriate box, indicating SLem is shc-m on plot plan below:
- - 51.1 3'7
~s - - - _ b -CBI $
LVFJJT 1
_O_Z I avcZ 6' 4i
Pt I
.I
TAP gL I J-
_ 5 y 8 ~ o P~1
7 - 1
1kil~ 'S-Mll 14 6f'--T-'P- VNlVE
K
L;~W`tE
t~c15T.
I'. ~Ni - ~I RP
,,lv YIo iITL~! of S I L) ? nl G
• iDO.o'
- _ I
By the granting or approving of the above plan, or upon the event of a subsequent
sr.c~oix County and the STCROix County Zoning Administrator, does
~eimit being issued,
not assume or hold itself liable for any defects in :plans or specifications, plan
scion, examination oversight, construction, or any dam _ that may result in or
after installation.
_
~P mbcr's signature