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AS BUILT SANITARY SYSTEM REPORT
COINER TOWNSHIP SEC. _T W
ADDRESS - ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WTTHIN 1.00 FEET OF SYSTEM
r
I di air N Pr h rrc w
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r
'I A I-1
BENCHMARK: (Permanent reference Point) Describe:""'"(
Elevation of vertical reference point: Slope at site: -
-4
SEPTIC TANK: Manufacturer /Liquid Capacity: c Number of rings on cover Tank manhole cover elevation: -
Tank Inlet Elevation: Tank Outlet Elevation: _
PUMP CHAMBER
Manufacturer: t • Number of gallons
Number of gal. pump set for a cycle gallons; T to~ 1 capacity of
distribution lines -gallon: size of pump head;
_ horsepower ;brand name of pump
gallon per minute
and model number
Type of warning device__-'~/ ___:f
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: numb.er of lines width length ,1" _tile depth
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
INSPECTOR _
UA'1'ED PLUMBER ON JOB--( -~!i .
'61 LICENSE NUMBER
161
~ ' vq
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
® CONVENTIONAL ❑ ALTERNATIVE State Plan I.D. Number.
% (If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INS EC N DATE:
Venn Munson R. R. 4, New Richmond, W1 _ :
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. EF. PT. ELEV.: CST REF. PT. ELEV.
NE SE, Section 4, T30N-R18W, Town o6 Richmond
Name of Plumber. IMP/MPRSW No.. County. Sanitary Perm, Number:
Cat Powms 1563 St. Croix 43660
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
PRO DED. PROVIDED:
~r,J~ . l J. I OJ, I YES ❑NO ❑ ,-t O
BEDDING: VENT DIA.: VENT MAT L; fGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDIN VENT TO RESH
✓j, LARM FEET FROM r LINE / AIR INL
[:]YES ❑NO Gi ❑Y O NEAREST A(
DOSING CHAMBER:
MANUFACTURER JBEDDING. JLIQUID CAPACITY PUMP MODEL FMP~S'PRON MANUFACTURER WARNING LABEL LOCKING COVER
P OVIDED. PROVIDED:
❑YES NO ' J 7J YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN ~J < FEET FROM LINF ; AIR"LEr
PUMP ON AND OFF) O YES ❑NO NEAREST S Ifs
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH 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. LENGTH JNI11 DISTR. PIPE SPACING COVER INSIDE CIA. UPITS LIQUID
BED/TRENCH / / J / TRENCHES MATERIAL PIT DEPTH
DIMENSIONS Chi)
- GRAVEL. DFPTH FILL. DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTH NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. INLET ELLEVJ. END PIPESr' LINE. AIR INLET 1 42 NEAREST-*► /J-~ w✓
~t~rU
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of t e fill material for PROVI A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to rrfa certain that it ON RE ERSE SIDE. SHOW ELEVA-
meets the criteria for edium sand. TION MEASURED.
❑YES ❑NO i/.
SOIL COVER TEXTURE JPERMANENT MARKERS OBSERVATION WELLS
/ ❑YES ❑ O ❑YES ❑NO
DEPTH OVER TRENCH.'BED DEPTH OVER TRENCH BED :=F TOPSOIL ISODDED SEEDED MULCHED.
CENTER EDGES.
❑YES ❑N / YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATERAL SPACING. IGR VEL DEPTH BELOW PE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES /
DIMENSIONS
MANIFOLD PUMP MANIFOLD D13TR. PIPE MAN FOLD MATERIA NO. DISTR. DI T I PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA.. EjEV.'. ! PIPES D A.:
ELEVATION AND
DISTRIBUTION i
INFORMATION HOLE SIZE HOLE SPACING DRILLED CQRVECTLY /VER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
' ✓ PLANS
✓ES NCII ❑YES ❑NO
COMMENTS: PERMANENT MARKERS J+~- FsEkYA ON WELLS: j NUMBER OF PHOPERTY WELL. BUILDING:
FEET FROM LINE.
❑YES ❑NO ❑YES ❑NO NEAREST
O q II~~ ~0~~ 13 3~I
G ~ I x.32 ~ U
Sketch System on \ 12 0~`~ - Remain in county file for audit.
Reverse Side.
SIGNATU~F(..E. TITLE.
DILHR SBD 6710 (R. 01/82) - /
7 w~sconsin APPLICATION FOR SANITARY PERMIT 4 l l
DILHR`'=e-~ COUNTY
~ ocvR (PLB 67) UNIFORM SANITARY PERMIT #
- InOUSTRV, LRBOR 6 HumRn RELRTIOf-15
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER, MA)LING ADDRESS /
PROPERTY LOCATION CITY: /
L- V-LLL-AGE: /
1/4, -
/4,S , TN, R (or W TOWN OF:
LOT NUMBER IBLOCKIVUMBER JSUBDIVIS~ON NAME NEAREST R AD, IrAKE OR LANDMARK STATE PLAN I.D. NUMBER
j.
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.
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):
Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of thaprivate sewage system shown on the attached plans.
Name of Plumber (Print): Signature; MP/MPRSW No.: Phone Number:
V X,
Plum b?r'sAddressa Name of Designer:
/f ;iJ~,r '.r~iii ii i,.~ _ - ~j ~r mot. ~ -,t.
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
o `r ~i' ❑ 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 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.
Furul - "j T C 100
1 V
v
1 Pruperty_
Location of Property, Sc ction N It f W
`i'ownahlp 1c„~~~,s~t
Ma illti s Address
i
Subdivision Nau►e u
Lot Nutuber A -
Previous Owner of Property
'total size of Parcel a Y-Qc< ~
t)ate Parcel Waa Created- -
17~
Are all CUCllera identifiable? _-Yeu
N~
luclude with this applicaClun one of the fulluwiu-L:
Certified Survey Mai,
r
~ . L) d
(.Land Contract, or
Other legal gocuuleut which describes the property
PROPERTY OWNER CERTIFICATION
I IWO certity that all Statements on this torm dre true to the best of (fly (our)
knowledge; that 1 (we) am (are) the owner - e propert ribed in this
information Corm, by virtue of it warra) y.dead recorded in the O tice of the
County RaUiitar of Deeds as Document d that I (we)
presently own the proposad site for the ewage d m (or I (we) have
obtained an easement, to run with the a property, for the
construction of laid system, and the lama has been duly recorded in the Otficc: ~
of the County Regiiter of Deeds, as Document No.
SI NATURE OF L1wNl;N SIGNATURE OF COOWNEH (IF APPLICABLE)
9- l.~
DATE SIGNED DATE SIGNED
FRUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
Vent Gap Feather Proof
Junction Box Approved Locking
Manhole Cover
12" Min '
Vent Pipe Final 4" Min
Grade '
Conduit
18 rain 18" Min
Inlet
Approved Approved
i
Joint w/ A Joints w/
C.I. Pipe C.I. Pine
Extending Extending
3' Onto i®Alarm 3' Onto
Solid ~'4 On B Solid
Ground Ground
C
Pump---~ ® Off
Concrete Block D
SPECIFICATIONS
TANK PUMP
Manufacturer >~~"~,yf',,,~ Manufacturer:
- W1P(0 3 d'70
Tank Material: Model Number:
Tank Size: Gallons Switch Type
Total Dynamic Head:- FT
CAPACITIES Pump Discharge Rate: GPM
Total Daily Effluent: Gallons
A = or Gallons Number of Doses: Per Day
B = or Gallons Dose Volume: Z'I } Gallons
C or Gallons Notes: 1. See pump curve for
D = or Gallons additional performance
Total Tank information.
Capacity Required = N Gallons 2. Pump and alarm are to be
installed on separate circuits
ALARM as per ILHR 16.19 WAC.
Manuf actur er SIGNED: JL - 5
Model Number: 411, ~ LICENSE,NUMBER-`
Switch Type DATE: _
i
8
Model 3870 Submersible Effluent Pumps
140
120
~A
ti
s
W 100 A
0
LL
f
80
= fyA
hIs
c 'p
O wAN70
a 7hp
6 60
wA
had h A
J
40 wPy05, h A
WPM03,1h H.P.
20 WP03, h H.P.
1
0 20 40 60 1 80 100 120
Capacity - Gallons P. Minute
Max. wt.
H.P. Order No. Volts Phase Amps RPM Solids (Ibs.)
WPO311 E
WPM0311E 115 94
. 1750 56
WP0312E
N/PM0312E 230 1¢ 4.7
WPH0511 E 115
36$
h W'PH0512E 230 8.0
WPH0532E 208/230 34
,IN W'PH0534E 460 3m 17
W PH0712E 230 10 9.0
34 WPH0732E 208/230 5.4
WPF10734E 460 3m 23 70
WPH1012E 230 10 116 3450 Y:°
i WPH1032E 208/230 64
WPH1034E 460 3m 3.2
WPH1512E 230 10 133
W PH i 532 E 208/230 9.2
ih WPH1534E 460 3m 4.6 80
WPHH1512E 230 10 13.3
I WPHH1532E 20B/230 9.2 30 J WPHH15UE 460 4.6
SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE.
3
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 7969
H).JMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION p - TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
4 /T (o0
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: j /
W1
USE DATES OBSERVATIONS MADE
NO. BED MS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑New ®Replace I r ;
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUNND-PRES~~S11URE: SYSTEM-IN-FILCH LDING TA :
K RECOMMENDED SYSTEM: (optional)
'
EIS EIU EIS ❑U E]S E]V E]S E]U OS E~ ,
If Percolation Tests are NOT required - DESIGN RATE: If any portion of the tested area is in the
under s.1-163.09(5)(b), indicate: r / Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH {J, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
1~ _ yam'
B- i
~ -
B-
B-
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 3 PER INCH
P-
P- A~ ~ ? L
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
4.C+1 ~ i
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Il - ®1ilE11
j I /~trS
y .
3
3
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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
7 _
CSTAIGNATURE
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil fester.
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Parcel 026-1014-90-000 01/23/2007 04:30 PM
PAGE 1 OF 1
a Alt. Parcel 4.30.18.51 B 026 - TOWN OF RICHMOND
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
DANIEL L JOHNSON O - JOHNSON, DANIEL L
1746 CTY RD A
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1746 CTY RD A
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 6.500 Plat: N/A-NOT AVAILABLE
SEC 4 T30N R18W 6 1/2A N 20 RDS NE SE E Block/Condo Bldg:
OF RIVER EXC S 100' OF E 200'
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/19/2004 769139 2619/030 WD
05/24/2004 763565 2579/015 TI
11/16/2001 662353 1765/01 TI
12/12/2000 635103 1566/333 QC
2006 SUMMARY Bill M Fair Market Value: Assessed with:
176700 184,300
Valuations: Last Changed: 06/19/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.500 60,800 82,900 143,700 NO
Totals for 2006:
General Property 6.500 60,800 82,900 143,700
Woodland 0.000 0 0
Totals for 2005:
General Property 6.500 60,800 82,900 143,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 306
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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