HomeMy WebLinkAbout040-1090-70-000
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Form - S T C - 104
1AS BUILT SANITARY SYSTEM REPORT
OWNER _O TOWNSHIP SEC., T _-27~N-R W
17
ADDRESS ST. CROIX COUNTY, WISCONSIN
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SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•HR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: !J Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: -
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: f: Tank Outlet Elevation: '
Number of feet from nearest Road: Front 10 Side 0 Rear, O feet
From nearest property line : Front,0 Side,0 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
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: Trench:
f,
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe: '
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: `=y Plumber on job: License Number:
3/84:mj
DEPARTMENTIOF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BO7,7969 BUREAU OF PLUMBING
MADISON, WI 53707 Yu ~}YCONVENTIONAL ❑ALTERNATIVE IS,,,, Pill l.D.N-ber
(If assigned)
t ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
/~lla
Doug Thompson 440 East Division, River Falls, WI ~-~j - - 10,',30
BENCH MARK (Permanent reference Po,,U DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV..
SW SE, Section 23, T28N-R19W, Lot #1, Town of Troy
Name of Plumber. IMPIMPRSW N... County. Sanitary Permit Number.
Dennis L. Hewitt 3186 St. Croix 48440
SEPTIC TANK/HOLDING NK:
MANUFAC TU ^ LIQUID CAP ITV. TANK INLET ELEV.. T K OU L EV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES 0 DYES ONO
71 (
BEDDING: I VENT IA.. - VENT MATL. HIGH WATER NUMBER OF ROAD: PR PP RTY/ WEL i BUILDING VENT TO FRESH
/ ALARM. FEET FROM r G, t~- \ LINF/, f F ~j! IAIR INLET.
v S JJJ
OYES ONO DYES ONO NEAREST 40
DOSING CHAMBER:
WARNING LABEL LOCKING COVER
MANUFACTURER. BEDDING. ` LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
PROVIDED. PROVIDED:
DYES ONO DYES LINO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of lowin t FN(iTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LNO. OF DISTR. PIPE SPACING; CO E INSIUE DIA. LIQUID
BED/TRENCH TRENCHES M PIT DEPTH
DIMENSIONS ~7 ~I`
GRAVEL DEPTH FILL DEPTH DISTR. D PIP DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL. / BU DING. V ,Q F SH
BELOW PIPES ABOVE COVER QJ.j i EL N PIP LINE /0 \ _ IN([~7A
~ FEET FROM
r NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIA9RAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE ~1DE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEAS RED.
DYES ONO
SOIL COVER TEXTURE PERMAN NT MARKERS BSERVATION WF ILLS
EYES O DYES ONO
DEPTH OVER TRENCH BED [EPTH OVER TRENCH BED DEPTH OF TOPSOIL SO DED _ SEEDED MULCHED
CENTER DGES ~❑Y NO ❑Y S DNO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM i
WIDTH. LENGTH . NO. OF LATERAL SPA NG~ GRAVEL DEPTH Q LOW PIPE r FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES N
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PI E MANIFOLD M ERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
FLEV.. ELEV.. CIA ELEV.. / PIPES DIA.:
ELEVATION AND
DISTRIBUI ION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL.
PLANS
EYES ONO DYES ONO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY fLL. BUILDING:
COMMENTS: / FEET FROM LINE
EYES NO EYES NO NEAREST
1 , / • I
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Sketch System on Retain in county file for audit.
Reverse Side. Gt~ ITITLE
u SIGNATURE l ~~~-^+a
DILHR SBD 6710 (R.01/82) C
wisconsin APPLICATION FOR SANITARY PERMIT 1 DILHR -~~%L--i-COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
OEPRRTMEnT OF
- InOLk TRV.LRBOR 6HUTRn RELRTIOnS 'J 9y Jj /1
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/,x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOE TION CITY:
~ -~.VI,~.LAGE:
)1/4 X1/4, S , T~ N, R (or) fowN~ F:r'
LOT NUMBER BLOCK NUM ER SUBDIVISION NAME NEAR ES ROAb, AK OR LAND 1 ARK STATE PLAN ID. NUMBER
t, `y zAY/'
TYPE OF BUILDING OR USE SERVED C~ O`er -`OQD G
1 or 2 Family Number of Bedrooms:- Public (Specify):
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.
❑ 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 c.
Holding Tank capacity
Manufacturer: LIZ
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): 13EQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signa ure: MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
UNA
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: / Date: /J l~ ❑ El Disapproved
&~G:✓u~ S~~" 6 Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
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 it
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.
Furin - S T C 100
Owner of Property M
.Location of Property "(,J Section R W
Township- + a
Mailing Address }fin )nom
R
Subdivision Name
Lot Number i
Previous Owner of Property )C~.ri.,n' QL~ A~- L'in
Total Size of Parcel f ~'-s -
Date Parcel Was Created - 98
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey Map
e
. =115concract , or
.Other Legal Document which describes the propert-
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best 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 da(4'record~d in the Office of the
County Register of Deeds as Document No.,1- and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an casement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
w4i^i6goF UIWNER ? sIGINA URE Co4WNEA 0 APPLICABLE)
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DATE SIaNEQ DATE SIG ED
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REPORT ON SOIL BORINGS AND PERCOLATION TESTS !,9
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701 1
OF NiN 98p r
LO CAT10N:'/4, S '/4, Section Z3 ,TN,R 19 E--(or} W, Township e~ I nicig3Tity
Lot No. - , Block No. County ST• C
Subdivision
Cl Ohl=1JGE Tt~ll PSayJ ame
Name:
Mailing Address: 24y 5 e~ fPtl~F'I~SIU ~~-1 V E ~1 uI_(,~ Stf G ZZ
TYPE OF OCCUPANCY: Residence ✓ No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS z-/ / PERCOLATION TESTS 12-1 W ao
SOIL MAP SHEET NAME OF SOIL MAP UNIT s°,~s rll~y Srta.~s M RG~OR
I: Q k-_" ca 37tcho'j `IWI S.
PERCOLATION TESTS
TEST DEPIH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM SINCE HOLE HOLE AFTE INTERVAL
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- \ 5 Ts 9 _E~n s i 7-S -7' L7 bbl wags L4 C-b P.JO \ U 13/5 7 jlN P - Z L4 5 M 8 ~I - z-: ti S it 1-7 7.0 IJD 3/a
3A -7
P- 3 y s 8 4 8 , S w lJO \ Sie 1 s'~ 1 Si' 6
P-
P_ tab sn~S`rnL-L _t~ D h v '~s`Tt~I 4 5`~ DMA - tNS s s N wEST
P 110►J C)I P ITI t. V I DG h 1 G \ S e
SOIL BORING TESTS
I-EST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 5o 1J01jg -2 Q0 31LTs 9~3nsi zz Qhs~ 1L! • ~3h 4,oQ s 44S
B- Z 1 4 IJok,t 7 ~y ,I .2-1 I ► LTN ~r_j:J s 1/ 3
B-- 3 g~ KJOwjf-:- 7 83 NS
B-- 5 8 4 Nome > F5 V , i z R11 s l' ZI T3A l ~T N V; 5 YV
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 3a4 ~'l1ZrCtIL s .Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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1, the undersigend, hereby certify that the soi0 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) Certification No. S7 6
Address Q0l31s, Z L-L_Sc,JCd1L'T')/ GU/. 5 V011
Name of installer if known - , p
Copy A - Loeoi Authority CST Signature
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In1ltrol,trI it and ul~si11 LUit aLtce of your u1)LI ysLL., roil f' t It it1
It-:, 1)rum it Lit rU Iit ilIt re Lo It,_tIIdIe wa -t c,. Troller uulinteuancu Cult
hits 01 1)U1111)111 uut - L}1c c1,Li c tank cruel y three years 0C 5uoIt c.r,
t i nUC(I ed, by I 1-ICC'It tied at ltI is L:III Ituiill,c i What you flat into
t llc sy:aLrw c'it u ril l t~cL LI l uI I cL iun ul t i~~ :t 111 is lnnl: a:; t Lru~IC
nc Itt take i11 1 he was LU disl,uSit 1 r;yriLeIll
1 CroIX C0till ty rcL-i L dCl1L:i liluy be elil-,I I t., Ic'rc,ivr I ~;r.tul lol
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waxitit Lt Ili u1 00X oI Chc co I of ro1)1UCIll enl_ I. I tai I iii ynteIll
which wa;, it ol,erat._iun i,riur Lu 1Lt .ly 1, 1~)lti 5C Crui_X County
.Il t.Cllt ud tit It, I,ro l;raIII itI, the t I u i I Ill I•it i IIt it t
~wnc I ut al 1 new y:.tl Ill yr;t t Ins.
I'he llrullurt.y wnoI I ;rctr:, lu uhnllI Lu Sl CruIX Couit Ly it it
cart it icci1 1 o I I I urIll siI;I1Ut1 I,y Lilt, owner and by a Mast Ur ltluulbel-,
jttit rit uyill a n 1) ill 1)eI restlit~ted i>-luwbcr ur ~.I I icenseil 1, c1Ill I vUri-
I Y iltg that (l) file to -:a i Le wit SLrwatt,r sal Sy~:teui llrc.ther
c rat iitl coIILIIC iun r.,utl (Z} .tl tI- ItI,,11i t.L and huwhiut~, (i l I I ct•_
~.iitry) tlti: rcptic' Lauk it. a0than IIul1 of sludp,c ..tad SCuui
Ct rLil is ittio[I IUrill will sent. A1)1)1'0XIIIlatC y 30 day5 hr.iur. Co
tlirUU ye.t.iI CY.1) 1Lt L)II '.I
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1/WI?, the it it deri_1{nrd, IIaVI• I ii tllt, Illuvt, I- (IU reIll U1)t and itI,I"ce U)
1u waIIILit l Lhc I Vate t;cwal;c, (Ii sysLuni iII uccuIlki11cc wi_LIt
thL' sLit CldaIF dS L lurtI I , IIC1:0i11 , :~tl 1) y Lhe Wir;coit,I iit UVItarL - .U
Ill oIt C of NaLUra L It c~SUUrcU:s Cur L i I icit L it I oral Ill Lt 1; C be conic) let- ed
and returned to L I I 5L. Crud-x C ounty X IIII1 OI 1 i_ee wiLIt iIt d'Iys
cal r.ht~ Lhicc ytur t•xl>irat i~,n dtltc~
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