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AS BUILT SANITARY SYSTEM REPORT
OWNER CA nc- ~i TOWNSHIPS yL i1 SEC. Z,... T ~?N-R jl W
ADDRESS 0'+ iST. CROIX COUNTY, WISCONSIN.
JI)y
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
R Ow _ EVERYTHING WITHIN 100 FEET OF SYSTEM
5 -
f 1
j
di a e oath Arrow
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: le-le- Slope at site: SEPTIC TANK: Manufacturer:
Liquid Capacity: Number of rings on cover Tank manhole cover elevation: -
Tank Inlet Elevation: 4,,1 Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: ( Number of gallons
Number of gal. pump set or a cyc e gallons; total capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower ran name of pump
and model number - 6 ;
Type of warning device /zJr'
HOLDING TANK: Manufacturer Number of gallons _
Flevation of manhole cover
To of warning device_
SEEPAGE PIT SIZE: Number o pits feet diameter
feet liquid d'ept~i seepage pit in e pipe-elevation
bottom of seepage pit e evasion feet. ,
SEEPAGE BED SIZE: number of lines width 1&figth ~ the depth
SEEPAGE TRENCH: w dth length
PERCOLATION RATE REA REQUIRED REA AS BUILT S`
INSPECTOR
DATED` PLUMBER ON JOBS 1
LICENSE
FL '?►.i►
hNv*• 7
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
EXCONVENTIONAL EALTERNATIVE state PlanLD Npmbe,
Ilf assigned)
Holding Tank ❑ In-Ground Pressure E Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DOTE'
Cain, Rodney Deer Park, WI 1 Y/ "70
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV.: v CST REF. PT. ELEV
SE SE, Section 6, T31N-R16W, Town of Cylon
Name of Plumber. MP/MPRSW No. Count
y Sanitary Permit Number'.
Cal Powers 1563 St. Croix 43702
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. I LIQUID C G LA
APAFs/ITV. TANK INLET ELEV.'. TANK OUTLET ELEV IWARNINBEL LOCKING COVER
fb,~i J(~~~A►^''••y PROVIDED'. POVIDED'.
EYES EjD,LDR~
BE
DDINGVENT DIA.ENTMATLHIGH WATER NUMBER OF ROADPR OP ERTV WELLING: VENT TO FRESH
ALARM FEET FROM LINE LAIR INLET:
EYES ENO EYES ENO NEAREST-
DOSING CHAMBER:
MANUFACTURER JBEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED:
EYES ENO DYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING IVENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) EYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH FDIAMliER MATERIAL Al. 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 / ~L` ~j s TRENCHES NAR~IA'IT DEPTH
GRAVEL DEPTH FILL DEPTH UISTH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DI iR NUMBER OF PR OPERTV WELL. BUILDING. VENT TO FRESH
BELOW PIPE r ABOVE COVER ELEV. INLET ELEV. END
-7 PIPES FEET FROM LINE AIR INLET
NEAREST-s
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-
E YES ENO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS ERVATION WELLS
EYES NOYES NO
DEPTH OVER TRENCH .'BED DEPTH OVER TRENCTBED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED.
CENTER EDGES.
EYES ENO EYES DNO EYES ENO
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 MATERIAL. NO. DISTR DISTR. PIPE DISTRIBU I ION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.. DIA. ELEV. PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COHRF_CTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
EYES LINO EYES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
e FEET FROM LINE.
E YES 11 NO DYES O Nm NEAREST
Oil, ,1 w
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHR SBD 6710 (R. 01/82)
wlsconsln APPLICATION FOR SANITARY PERMIT
~I DILHR (PLB 67) 6-1 e COUNTY
oERRRTmEnT O❑ UNIFO))rPM SANITARY PERMIT #
OUSTRV, LR90R 6 HUMRn RELRTIOnS ` - ,
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY"L0CATION CITY:
VILLAGE:
1/4 1/4, S , T_ , NR E (or) W TOWN OF: /
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER
Li 'f
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ 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.
L!r-,! 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
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):
1' 0 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation the private sewage system shown on the attached plans.
Name of Plumber (Print): Sig re MP/MPRSW No.: Phone Number:
'71T LVi(",
Plumber's Address: ! Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
0 A"" .I,
Signature of Issuing Agent: ee: Date: ❑ Disapproved
6 -ddt~ ❑ Owner Given Initial
\ a 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.
ForaI - S T C 100
Owner of Property r 61') d
.Location of Property Section
'1 Z , N k W
Township
Mailing Address r
Subdivision Name
1o-t Number /
Previous Owner of Property
-Total Size of Parcel
Data Parcel Was Created 19U-iit
Are all corners identifiable? V Yes No
Include with this application one of the following:
.Certified Survey Map
Deed
-.Land Contract, or
.Other tiegal Document which describes the property
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 propect~deseribed in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document N&1 .-arid that I (we)
presently own the proposed site for the sewn a di
g sposal system (or I (we) have
obtained an easement, 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.
SIGNATURE O o N6R SIGNATUR FO~OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
pdv3' n~tri01
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: OWNSHIP/M-UN[CIPALITY: LOTNO]BLK.NO.: SUBDIVISION NAME:
1 ~T= H/R (or) W
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
=r
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATI N TESTS:
O Residence 0 New El
Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
Q S ❑ll S ❑U EIS ❑U ❑ S ❑U ❑ S ❑U
[uf Percolation Tests are NOT required' DESIGN RATE: [Floodplain, any portion of the tested area is in the
nder s.H63.09(5)(bl, indicate: indicate Floodplain elevation:
~ J
PROFILE DESCRIPTIONS '
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL ' WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH tf OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
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
0 _43
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a E
3 ,
i
4
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a
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T
3 \
•
3
3
3 j
I, the undersigned, hereby certi$y 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: p CERTIFICATION NUMBER: PHONE NUMBER (optional):
CSyS7G UR ~ -
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Teste
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77-
RUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
Vent Cap Weather Proof
Junction Box Approved Locking
Manhole Cover
12" Min
4" C.I. ;
Vent Pipe Final _
Grade 4" Min
I '
Conduit
18" Min 18" Min
1I
Inlet
Approved
Joint w/ Approved
A Joints w/
C.I. Pipe C.I. Pipe
Extending
3' Onto Extending
Alarm 3' Onto
Solid ' On B Solid
Ground
Ground
C
Off
Pump -
Concrete Block ~ D
SPECIFICATIONS
TANK PUMP
Manufacturer Manufacturer:
Tank Material:
Model Number:
Q
Tank Size: -Gallons Switch Type
Total Dynamic Head: - i FT
CAPACITIES Pump Discharge Rate: 210) GPM
Total Daily Effluent: J42 Gallons
A = or Gallons Number of Doses
Per Day
B = or ZY Gallons Dose Volume: Gallons
C; or Gallons Notes: 1. See pump curve for
D = or e) Gallons additional performance
Total Tank information.
Capacity Required Gallons 2, Pump and alarm are to be
installed on separate circuits
ALARM as per IL R 16.19 WAC.
Manufacturer: - SIGNED
Model Number: LICENSE NUMBER-:
Switch Type DATE: < <
G
Parcel 006-1012-40-000 09/19/2006 04:02 PM
PAGE 1 OF 1
Alt. Parcel 6.31.16.91 B 006 - TOWN OF CYLON
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
O - CAIN, RODNEY J & CATHY
RODNEY J & CATHY CAIN
2020 CTY RD H
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 2020 CTY RD H
SC 0119 AMERY
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 18.681 Plat: N/A-NOT AVAILABLE
SEC 6 T31 N R1 6W 18.681 AC E 501.24' OF Block/Condo Bldg:
SW SW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-31N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 528/45
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 09/08/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.680 25,000 139,000 164,000 NO
UNDEVELOPED G5 14.000 16,800 0 16,800 NO
Totals for 2006:
General Property 18.680 41,800 139,000 180,800
Woodland 0.000 0 0
Totals for 2005:
General Property 18.680 41,800 139,000 180,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00