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t AS BUILT SANITARY SYSTEM REPORT
OWNER ; 1) X S TOWNSHIP` r-i4o SEC. T N-R W
ADDRESS ~J _ 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
11k
1~Ry
/I
i
1 INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used /rte irey~°
Elevation A vertical reference point: ~//y1~17 Proposed slope at site: fJ
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
`lank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, O 170 feet
From nearest property line Front,0 Side,&Rear, o feet
Number of feet from: well f~ building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
UMP CHAMBER i
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inl Bottom of tank elevation:
Pump off swi h elevation: Gallons per cycle:
Alarm Ma facturer: _ Alarm Switch Type:
Numbe of feet from nearest property line: Side, O Rear , Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: t Number of Lines: C Area Built: 7•5~0
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, Ft ~J
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 rop box O or distribution box O been used on any of the above soil
absorbtio sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings sed: Elevation of bottom of tank:
Elevation of 'nlet:
Number of eet from nearest property line: FronO Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
r
f
Number of feet from nearest road:
r"
Alarm ranufacturer:
Inspector: _
Dated: Plumber on job:
• - - (7 '
i
License Number: 4
3/84:mj
SAFETY & BUILDINGS
INSPECTION REPORT FOR DIVISION
DEPARTMENT OF INDUSTRY,
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING
P.O. BOX 7965t state Plan I.D. Number:
MADO SON, W I 53707 CONVENTIONAL ❑ A LT E R N AT I V E (If assigned)
Mound
D
❑ Holding Tank El In-Ground Pressure
~
INSPEC ION DATE
ADDRESS OF PERMIT HOLDER: W1 54023
NAME OF PERMIT HOLDER. -R • R. 1, Rv bext/S , 1
RE PT. ELEV.: CST REF. PT. ELEV
Hv man. Ho"tey
BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN
Uwom'en'
NW NUI, Section 25, T29N-R19W, Town ~ SamtarY Permt Number.
MP/MPRSW Nc).. Cou ntv. 49486
Name of Plumber. 3254 St. cxoix
Garay Steel.
TANK O TLET E EV.. WARNING LABEL PROVIDED OVER LOCKING SEPTIC TANK/HOLDING TANK: LIQUID CAPACITY TANK INLE Ev~~ / PROVIDED:
MANUFACTURER r _1 ❑YES ❑NO B❑YES ❑NO
I PROPERTY WELL UILDING. JVENTTOIRESH
- ROAD. AIR IN LET.
VENT MAT HIGH WAT -H NUMBER OF ' LINE.,
: VENT DIA. ALARM
BEDDING . FEET FROM lr
C- ❑YES ❑NO NEAR
❑YES ❑NO EST
PUMP/SIPHONMANUFAC:IURER WARNING LABEL PROVIDED OV ER
DOSING CHAMBER: PUMP MODEL PROVIDE ES D ❑N O
BEDDIN QUIDCAPACITV ❑YES ❑NO
MANUFACTURER' G: u Y
PROPERTY WELL BUILDING (VENT TO FRESH
NO AIR INLET
❑YES ❑ .
PUMP AND CONTROLS OPERATIONAL. NUMB LINE
GALLONS PER CYCLE: FEE RO
(DIFFERENCE BETWEEN ❑YES ❑NO NE EST MATERIAL AND MARKING
l_F (;TH 1)IAM FT EN
PUMP ON AND OFF) FO CE
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing hallcease u ntil
M N
or excavation. (If soil can be rolled into a wire, construction s
the soil is dry enough to continue.) INSIDE DIA aPITS LIQUID
DEPT R.
CONVENTIONAL SYSTEM: LENGTH No. DF DISTR PIPE SPACING COV ~A PIT
WIDTH TRENCHES 1
BED/TRENCH 70 - J PROPERTY WELL BUILDING VENTTOF7
DIMENSIONS NO DI H NUMBER OF AIR INLET
FILL DEPTH UISTH. PIPE DISTR PIP DISTR. PIPE MATERIAL. PIPES FEET FROM LINE
/
5J
GRAVEL PEPTI~ 2 /
BELOW PIPES ABOVE COVER EI -V INLE ELEV E PIP
NEAREST-------
2
MOUND SYSTEM: PROVIDE A DI RAM OF SYSTEM
Mound site plowed perpendicular to slope Check the texture of the fill material for ON REVER IDE. SHOW ELEVA-
and furrows thrown upslope: mound systems to make certain that it TIONS A RED.
meets the criteria for medium s nd.
NO BSERVATION WELLS
❑YES ❑ P NE NT MARKERS.
SOIL COVER TEXTURE S ED ❑YES NO ❑YES MULCHED ❑NO
DED
DEPTH OVER TRENCH' BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL ❑ ❑NO ❑YES ❑NO
CENTER EDGES. ❑Y S ❑N Y
FILL DEPTH ABOVE COVER.
PRESSURIZED DISTRIBUTION SYSTEM: NO. OF LATERAL SPA G, GRAVEL D PTH BELO IPF.
LENGTH W IDTH TRENCHES.
BED/TRENCH .
DIMENSIONS MANIFOLD ATE AL NO DISTR IA R IPE DISTRIBUTION PIPE MATERIAL & MARKIN IST PUMP MANIFOLD DISTR. E M PIPES D
MANIFOLD
ELEV ELEV. CIA ELEV
.
ELEVATION AND VERTICAL LIFT CORRESPONDS TO APPROVE
COVER MATERIAL PLANS.
DISTRIBUT ION HOLE SIZE HOLE SPACING CHILLED CORREC Y ❑YES ❑ ND
❑YES ONO PROPERTY WELL: BUILDING
INFORMATION
OBSERVATION WELLS: NUMBER OF LINE.
PERMANENT MARKERS: FEET FROM
COMMENTS:
❑YES ❑NO ❑YES ❑NO NEAREST
tc•
-to
l~J N
county file for audit.
Sketch System on TITLE
Reverse Side. SIGNATURE. -
r~
DILHR SBD 6710 (R. 01/82)
N FOR SANITARY PERMIT ~couNTY
APPLICATIO
1 L H R (PLB 67) UNIFORM SANhTARY PERMIT #
lit T En-r OF R`~, LR60R 6.1JMRn FIELRTIOnS
Ez,_
-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. MAILING SE PRINT
PROPERTY OWNER
CITY:
P OPERTY LOCATION VILLAGE:
1/4 1 f, /4 S ' TN R E (or) W TOWN OF: T ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
LOT NUMBER BLOCK NUMBER 1bubDIVISION NAME -00
TYPE OF BUILDING OR USE SERVED r~ rW a~-'" la~2d
❑ Public (Specify):
1 or 2 Family Number of Bedrooms:
THIS PERMIT IS FOR A: ❑ Repair
New System ❑ Tank Replacement ❑ Privy
El Replacement Soil Absorption System El Revision 1-1 Reconnection El Petition for Modification
El Alternate System
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK ❑ Seepage Pit ❑ Holding Tank
❑ Seepage Bed E4 Seepage Trench ❑ Pit Privy
❑ In-Ground Pressure ❑ Vault Privy
System-In-Fill
issued
❑ Existing, For Which A Previous Permit Is On File, Permit #
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Steel Fiberglass Plastic
Total #of Prefab. Site
Gallons Tanks Concrete Constructed
Septic Tank Capacity A
Lift Pump Tank/Siphon Chamber
Holding Tank capacity j
manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Plastic
Total #of Prefab. Site Steel Fiberglass
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
PERCOLATION RATE
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private El Joint Public
❑
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on he attach
Nod: plans. Number:
re:
/
Name of Plumber (Print(: Signat u
Name of Designer:
Plumber's dress:
i i
COUNTY/ DEPARTMENT USE ONLY Disapproved
Signature of Issuing Agent: Fee: Date: Owner Given Initial
~4k Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
DILHR-SBD-6398 (R. 5/82)
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.
APPL.ICA`C ION VOI: SANITARY Pl?RMI`l'
S T C - 1.00
This application form is to be completed in {111.1 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 - A 1" /')'t a ILL
Location of Property Section .F N R W
Township
Mailing Address
Subdivision Name AJOA
Lot Number
1
And geyx
Previous Owner of Property
'total Size of Parcel
!),,rte Parcel was Created d
No
Are all corners and lot lines identifiable? Yes
YesNo
[s this property being developed for resale (spec house)
ry r
Volume and Page Number 3 b 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
M,ip, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTV OWNER CERTIFICATION
7 (We1 cep-tiny that at Atatemen A on thi,s norm ane true to the best on my (oun.)
f',nowkv,dge; that T (we) am (one) the owneA (A) on the pt opefrty desni.bed in this
i.nno by viA tue o A a waA ant y deed neeonded in the. O n n) ee. o n the
nma~,%an nvnm, and t(a~ I (we)
County Reg~teh on Deeds as Document No. ~ m (on I (we) hove.
pne,5(Wl,y own the. pnopoAe.d Aite non the- aewage tzpo ~ yahe the
obtained an. easement, to nun. With the above. dmcA~bed pnopet~-ty, non
eon6tA,ucti.on on bard system, and the, same hays been du-2y ne.cond,d in the Onnice
on the County Regi's-ten on DeeA, a6 Document No.
SIGN TK~RE OF 0-OWNER (IF A .LICABLE)
SIGNATURE OF OWNER
/;~_z , A:,
DATI: . pl~-IGNE'I) DATE S'~NED
H
Vj
• Y
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SV,PTIC TANK MAINTENANCE AGREEMENT o
St. Croix County
d
y
OWNER/BUYER -/na_Lj_ e 11710 ~y C'
ROUTE/BOX NUMBER Fire Number
- ,1
CTTY/ STATE E~"~ deS e, _7IP Sal
0, -
PROPERTY L0CAT10%, AIIJ IUi,d t4, SectionA5', T=A? N, R_ W,
'f'awn of__~A/1:1_r r :,n St. Croix County,
Sulbd.ivision. -,e- Lot numb errn_t_.
I
T_mproper_ 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 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 maxi _mum 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 a1.1 new systems <i}t,rce ?o 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.-sate 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
:~i:
te~
T/WE, the undersigned, have read the above requirements and agree U
to maintain the private sewage disposal system in accordance with H
the standards set forth., herein, as set by the Wisconsin Depart- ~
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 date.
SIGNED
St. Croix County Zoning Office
P.O. Box 227
]lammon.d, WT 54015
715-796-2239
Sign, da+e and return to above address.
DEPA'i4;-PvIEN-T OF REPORT ON SOIL BORINGS AND SAFETY & t3UIL S
ON
iNDUS'fRY, DIVISION
LABOR AND, 1 C P.O. BOX 7969
HUMAN RELA,~fIONS PERCOLATION TESTS (1~J) MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOC TION: SECTION: TOWNSHIP/MUNICIPALITY: OT NO.: IBLK. NO.: SUBDIVISION NAME:
/~iJ / ;2,s /T N/R or pn H N~ / -
COUNTY: OWNER'S BUYER'S NAME: I MAILING ADDRESS:
O i Y ,114E ! S 1 c n r1 0 oOt o ,I( x- T PAa G rn *'o h. SS/a G/
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILED IPTIONS: ER LAT ON TESTS:
~r ® New El Replace Il l 6 L~ 6 L/ 4
Residence
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMEND D SYSTEM:(optional)
ZSDU MS❑U ~SDU DS U DSL~9ll - sX75'T~~
Eunder rcolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS Pj 6 F
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 9, 0 25.4
B- $.0 93.6 o ve o„~h.sL 13&.cL Y60 wsof.s
B- y ,O' o yN Qh. S / 9 Q c l 1.0
B- 6.f O &A. S ! 6 „ n C I 5 ~ A 4,117d. s
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P--~
P- 3- y v o N
O
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 • 6
f ;
~o e- O'n gwYWer4
t ;
t_ - N
l
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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:
Tx P ke A- L -9-
ADDRESS t CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIG AT RE:
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