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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP
SEC. I T N-R W
2~1)DRESS= ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LO'T LOT SIZE
PLAN VIEW
Distances and diulellsions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
16
i a t N r h r r w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point r --Slope at site: s'
SEPTIC TANK: M~lnufacturer~; od_ Liquid Capacity
Number of rings on cover
Tank. manhole cover elevation:
Tank Inlet Elevation:
----`L'eak Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number (_)f gallons
Number of gal. pump set for a cycle- gallons; Total capacity of
distribution lines------gallon:
gallon: size of pump head;
gallon per minute- horsepower ;brand name of pump
and model number
Type of warning device____",(
HOLDING TANK: Manufacturer--------- Number of gallons
Elevation of manhole cover _
Type of warning device
SEEPAGE PIT SIZE;
Nu111ber of pits feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation__ feet.
SEEPAGE BED SIZE. number of lines-- - width- length the depth
SEEPAGE TRENCH: widthlength---
PERCOLATI'.)N RA'Z'E AREA REQUIRED 3 r ~AREA AS BUILT?- X
INSPECTOR
DATED i PLUMBER ON JOB T~~
L I C E N S E N U M B E F: _r. Y -r`_, -
DEPARTMENT OF INDUSTRY
LAAO.'.&•HUMAN RELATIONS INSPECTION
P.O. BOX 796e,>' REPORT FOR
MADISr„ I, wl 153707 PRIVATE SEWAGE SYSTEMS
SAFETY & BUILDINGS
❑ CONVENTIONAL BUREAU OF P DIVISION
LUMBING
Holding Tank IXIn-Ground Pressure TERNATIVE
State Plan LD. Number
NAME OF PERMIT HOLDER: Mound It a"Igned) Harry C. Wolf ADDRESS OF PERMIT HOLDER 8105883
T~ `
BENCH MARK IPennanent reference point) DESCRIBE IF DIFFERENT FRO R lAN
Box 120, Baldwin , W1 INSPECTION DATE
NE NE
er , Sec 1, T28N-
Name of Plumb R 1 7 W, Town Of Rush River REF. PT. ELEV. CST REF PT ELEV
Robert J. An MP'MPRSW No
Anderson
SEPTIC TANK/HOLDING 2924 e Sanoa'y Permit Number
MANUFACTURER: TANK: S t • Croix 3 8 4 9 6
7
•
BEDDING. LIQUID C P
A ACITY TANK INLET ELEV
\ ? TANK OUTLET ELEV
VENT DIA.: I t t WARNING LABEL
VENT MATT. PROVIDED: LOCKING COVER
❑YES /1 JHIGH WATER IN ES NO Tl C ALARM NUMBER OF ROAD INES ❑NO
PROPERTY WELL YES
DOSING C I FEET FRM G
YES O
CHAMBER: ❑NO NEAREST- LINE BuILOw
MANUFACTUq ER - LAV IERN T TO F Ipyt,H
! BEDDING: T
G y` L, LONSPER LIQUID CAPACITY PUMP MODEL
EJYES NINO
CYCLE: w PUMP;SIPHON MANUFACTURER I
A J ~j Z~
(DIFFERENCE BET WARNING LABEL
WEEN PUMP AND CONTROLS OPERATIONAL P DIVIDED LOCKING COVER
PUMP ON AND OFF) PROVIDED
SOIL NUMBER OF PROPERTY YES ❑NO [YES
0 excavatio. ❑NO ROM NE
T TO O
ABSORPTION SYSTEM. Ch eck the soilmoisture at th depEh of plowing FEET F WELL BuILDING vEN NO
n FRESH
the soil is dry enou ugh to conti tinue.)
(l soil can rolled into a wire, construction shall cease until NEAREST LAIR INLET
CONVENTIONAL SYSTEM: FORCE LEN
- DIAMETER MATERIAL AND M
gHKING
BED/TRENCH WIDTH LENGTH MAIN
DIMENSIONS NO TRENCHES' DIS R PIPE SPACI
'COVER
G VET. NG
RA
BELOW PIPDEESPTH FILL DEPTH MATERIAL: INSIDE DIA
ABOVE COVER DISTH. PIPF DISTR. PIPE PIT I S
ELEV. INLET ELEV END DIS IPE MATERIAL- LIOU ID
. : %
NO. DISTH. NUMBER
PIPES OF PROPERTY DEPTH.
MOUND SYSTEM: FEET FROM LINE WE UiLDING VENT TO FRESH
NEAREST- site plowed perp AIR INLET
endicular to slope
and furrows thrown upslope: Check the
texture of he fill material for
mou"d systems tq ke certain that it PROVIDFiA OIA M OFSYSTEM
❑YES ENO me s the criteri ON REV R
SOIL COVER TEXTURE or edium sand. / S~bE
TIONS E SHOW ELEVA-
~ SURE
PERMANENT MARKERS.
DEPTH OVER TRENCH BED CENTER DEPTH OVER TRENCH
ED SER Vq ION,&Ey„E.g...
EDGES. DEPTH OF TOPS IL f f
YES SODDED O
DIED . YES
PRESSURIZED DISTRIBUTION SEE
0 ? MULCH ❑NO
ED
SYSTEM: YES ❑NO e j
BED/TRENCH N1D7H LENGTH ❑YES NO, ❑
DIMENSIONS THEN _ LATERALSPACING: GRAVEL DEPTH BEL~PIPE O OYES ❑NO
3 3 TRENCHES ~ /
MANIFOLD PUMP (/y FILL DEPTH ABOVE COVER
:
ELEVATION AND ELEV MANIFOL
ELEV D DISTR PIPE DIA DISTRIBUTION ~ ELEV / MANIFOLD MATERIAL
NO DISTR
INFORMATION NOES DIASTR j R. PIPE DISTRIBUTION PIPE MATERIAL ,Q MARKING
HOLE SIpE HOLE SPq CING DRILLED CORRECTLY DI /
t11/I> COVER MATERIAL Y- Z
COMMENTS: V YES VERTICAL LIFT CORRESPONDS TO APPROVED
PERMANENT MARKERS. NO PLANS
I r OBSERVATION WELLS:
u1ES NUMBER YES ONO
~NO PROPERTY WELL:
4J YES ONO FEET FROM LINE BUILDING
_ NEAREST
Sketch System on
Reverse Side.
Retain in county file for audit.
DILHR SIGNATURE
SBD 6710 (R. 01/82)
TITLE.
cPA-RTMENT OF
I,N DUST,R y, T -9 111, WPLICATION f
LABOR AND , FOR SANITARY SAFETY & BUILDINGS
HUMAN RELATIONS .i c= PERMIT DIVISION
(LB 67) P.O. BOX 7969
MADISON, plans for the system on WI 53707
and vertical elevation reference points must be shown.
Paper not less than 8'% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
H-63, Wis. Adm. Code, must be shown. All appropriate separating distances and physical characteristicsIf
Plumber, the date, signature and license numn index betlmuspt be shownh page must be signed, sealed and dated by the . a Master
designerasdesignedspecifiedbyin chapter
included. The owners copy or a legible reproduction of the soil test report must to
Property Owner:
Mailin
r ) L J~ g Address: ALI
IL $-f
Property Loc tion: 2-6 ~t,
' V 1
%a )Ze %a$ ~T 2-?11\11R City, Village or Township:
Lot Number: r E (Or) W ~U County:
Blk No.: Subdivision Name: f
Nearest Road, Lake or Landma k:
TYPE OF BUILDING 3 State Plan LD. Number:
C (If assigned
Public* Q L~ ~
❑ Variance* ❑ Other (specify)*
1 or 2 Family *State Approval Required. Number
Bedrooms:
s:
TOTAL NUMBER
SEPTIC TANK CAPACITY GALLONS OF TANKS PREFAB POURED-IN
CONCRETE PLACE STEEL FIBERGLASS NEW REPLACE-
HOLDING TANK CAPACITY INSTALLATION OTHER
MENT (Specify)
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM x
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New
1i a y l ~ Replacement
-S~-FF. El Alternative (specify) ~ ❑ Experimental ❑ Seepage Bed
y) L/10 ❑ Seepage Pit
,s !zn I
❑ Seepage Trench
Water Supply; I
Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
ff e011 C . GUO
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on
Nare of Plumber: the attached plans.
t!~i f~ a✓1 i~ t~ ~3 4 Signature:
Plumber's Address: MP/MPRSW No.: Phone Number:
y ~°i ~3 (+I S Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Si natur of Issuing Ages
Fea Date: gy~pp{(
Reason for Disapproval: .+~i.APPROVED Sanitary Permit
Number: I
❑ DISAPPROVED S
Alternate course(s) of Action Available:
i
MAR
Change of ownershi i
p, building use or plumber requires a Sanitary Permit Transfer Form ( S 67-T oFt5t~b
stallation. Failure to comply will void the sanitary permit. T
t~fii ~`~h~Q~c~unt
y prior to in-
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03/81)
1' u r w 5 1' L l U U
Owner of Property
X) X1,
Luc ation of Prope rty4L-//!---_=ti~/Z =4, Section -N 11~ W
T u w n w h 1 P.___)L L
Mailing, Address~~
Subdivialon Naha
LOC Nu(uber
Previoua Owner of PrOptrcy Z Z("~
TOtal Size at Parcel
Date Parcel Vde Created
Are all corucru ldentltiable'f _ Yes _ ---.---.___Nu
lucIudu w1Lh Lhtz, a)i1,lt~ 1L1, uu unu ut~LI1, LuiluwilII
(;ertitied Survey Mali
Ueed
Land Cunt. rdct, Or
Uther legal UucuUIent which de~,cribe5 the pCOIJULY
I
PROPERTY OWNER CEHTIFICATION
(We) certity that all statements on this turnn are true to the bust 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 Hegiiter of Deeds as Document No. ; and that I (we)
presently own the proposed site for the sewage disposal 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.
~L2
0, i , lz~e L444
SIGNATURE OF O ER SIGNATURE OF CO-OWNER (IF APPLICAULE)
UATE sIGNEO UATE SIGNED
rwp c CER I" CATO"
#Efi
W/,SC'Qms//V. co. James F. Simonet
M1~CONeyM RLOiMrm4t, LAMD 9U'"roi' '.4j, I*-"I
A4Rr OF
r zgN /:rw
~7•
0144
L~iD I~3QBIP~ZQNi
~ I
The Seth 259 ft, of the south
zc c~..y.. ~0 324 ft, of the Nmst 337 ft. of
the North 1/2 of Nowt 1/4
Q~s ► - - Q 7IRaa 1/3 of NN 1/4 } e; sea. Nr.
Qorq r' fl ~f' • T281. 217W. Rash Hider •"b',
a, stw, Croix County. Yiscensin.
3s' 06atai'd*g 2 acres more or loma.
f snbJOet to the right of way of
,x.8y _boa y,► ~ Visconain aghww so- 630
~ X37 • . y .
/;/~'Z 4"e- I'vel. r d'C; - -
I
Durvey made 'fort Ourrell Realty Co. Inc. st. I'su1. Minnesota.
I hereby certify that I virveyed
that thm above is true and correct p,at~of said isurvey. he`property deacribcd above and
14, October, •1966
Scaler 1» - loot
James P. simoaet
N. B. L. sn No. s 6oi
. SIMOnd
SURVEYOR
S~il~tert~rrac~tt
State Of Wisconsin Department of Industry, Labor & Human Relations
Division of Safety & Bldgs.
Bureau of Plumbing Platting & Fire Protection
P.O. Box7969
Madison WI. 53707
Tel. 608-266-3815
INALL CORRESPONDENCE
?~J c C~ J REFER TO PLAN
> IDENTIFICA TION NO.
c_-
NAME OF PROJECT
f ~ r
TYPE OF C 7
STREE AND No.
Z
'e~lR TOWN
71
COLIN Y
' L'c' STATE ZIP
OWNER i
Gentlemen:
Examination of plumbing plans and specifications for the above-mentioned
e Wisconsin
Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications
iscon with the stipulations
indicated on the fans. Please review project has been completed. In accord with Chapter om-
are a proved ngent p your code for the requirements of eachp ode section Inot d upon com
The architect, professional engineer, registered designer, owner or
plans bearing the stamp of approval of the department. Plumbing contractor shall keep at the construction site one set of
In granting this approval, the Division of
omissions, examination and reserves the right to order changes or additions should condi
Safety and Buildings does not hold itself liable for any defects in plans or specifications I
This a dons arise making this necessary. ~ p an
ments
pproval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain
menu of the city, village, township or county in which this installation is to be constructed_ Failure to
m tic ly void this acceptance, and fulfill the permit require-
local permits will auto-
Sincerely,
For Private Sewage Systems O,nI
This approval is valid for two y
YF✓'a^ s O? it Wit.' `O Va[d uniii
thin eugpirafier,
tal
James Sargent-Bureau
Director
PLAN REVIEWED,
DATE:
cc: DP
Local PI Owner
Plumber DILHR
DILHR
DILHR 9BD-6099 (N, 06/80) Mfg. Rep"
H &
R (2)
Bur. of Health Fac. & Services
Rec" & Env. Services
lLc,--.
IPA7,
~~Po/,oSED
p,~'o7EC T"+ ~PE~GIICE.~-~E.vi sC=,dr/c sysTEM ~o~
~o x /2 0 (IZAG,P&,V cJ Cui S .
y 41,4- y S C,i . 7-2- ~N )P l7 w
~'Ut~. ~PivE~ Tb wN - S~• C/~oix Via=-.
e
'till Z STATE Cvo~f' S// C
(f ~
%
d/ST~i~UT M~}%N/FOLD
P,q y - 3^D U/E OF
~ J
p,~~ 5' _ C',poss SE o,v
CAb55 S~eT~oiv iv y,Qovvv ~/PESSv,P~
sysrE,~ SED
5' el /0 T1,O
Pz- Zo7 6,1rO A))
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WORKSHEET ~ PRESSURE DISTRIBUTION NETWORK DESIGN ~A I
PROBLEM
Design a pressure dicr,ributinh netw;,rk fpr', 3 bedroom home. The tc
characterisitics are:
Depth of groundwateW:'6i bedrock in.
Landslope 3
%
Percolation rate min./in.
Distance from dose chamber to distribution system 3 d ft.
Elevation difference between pump and distribution system ft.
Step 1. ESTIMATE WASTEWATER LOAD j,Po,-l
1S o ~s//~oM.~ aA
/5"v ~s~ 3 ~ o,~ ~ = yS~D ~ ~ ~ ~ /_~~Poorys
Step 2. SIZE THE ABSORPTION AREA f~oM 14 G 3,
i
A) Area required
c57 4(,4
I0/f0 At,eG st! w ~~J S~
B) Select length 37- fi•
C) Width is
D) I will use a manifold
tep 3. SIZE DISTRIBUTION PIPES
A) Hole size I will
. ) use 1 in.
B) Hole spacing I will use is in. C) Lateral length is ft, l
D) Lateral size / in. o,,r- 116 c.{S
Step 4. DISTRIBUTION PIP DISCHARGE RATE
~QoNI l~~/E G c^
P/ PC
I~ .
Step 5. SIZE MANIFOLD 1
I
~A) Manifold len th ft,
B) 'Number of dlstri' 4ution pipes
-
C Mani fold diamet r in.
er , -
I
79F 117.
I
~UOL~ -'CUES/U~.f/CC PA
Step 6. SIZE THE FORCE MAIN
A) System discharge rate 76/6-et 00
B) Force main diameter3 f'`'4"'`
C) Friction loss will be ft./100 ft.
Step 7. TOTAL DYNAMIC HEAD
fi
A) Vertical 1 i ft ft. 1A
F fob SyST-~-' 1. ~ '
B) Friction loss 2.5 Ic-7-.
f ~ ft.
C) TDH ft.
Step R. SELECT A PUMP Sa Z 5C3
Step 9. DOSE CHAMBER SIZE 5,vovj,6, -rog / PA yf ~P S~f'v~ t- Df'A/c>/3fJ o,~
(/p C ZG», f 4 L 7 Z( 00JE UD L?{~,,, = ~P 2 Ct .
y5 0 l, 7 S t lSU to~ 7 7S^C~
Step 10. DOSE VOLUME
71 OA-,,
&4- .0 P4
2 o L D 6 r71-
y f pi ~c S
,wry'
PC flall -Z 7
%o f,4 L C,410A Clfz, GL P) - Its 7
-f
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OCT 29 1981
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OCT 29 , .
:1981
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SAFETY & BUILDING`
RT(~ENT OF J""'vE T" N IL BORINGS AND Dlvlslor
k ` YY P.O. BOX 7961
L.ABOH ANN N11,4R 41092 TESTS (115) MADISON, WI 5370.
-HUMAN REI ATIONS
1L.0 A 10N S ? N ` f Q~ TO_WNSH`IP/MUNiCIPALITY: OT NO.: BLK. NO.: B V 5::1 &E:
'/°4 Fi ~:'4d_t r~ ✓ l. .
MA LIN ADDRESS:
.OUNTY: OYVNER S/tit1YE3 NA Mr~
p
r.fi ^
i of (i. ~rj~F j^fii ~ ~iti✓«.. dr _
- T DATES OBSERVATIONS MADE
- -
NO. P~DREJI,S. .COi~iMr_R~i ~A)_ L?ESGFiIP710NTENw S A TESTS:
,y -
_Replace iA s fp v ~r"%'
` ,ssdfnre I ~ c e.' r 3
i
G: S Site suitabdt for system U= Site unsuitable for system --s -
G r"RfT ) vAt_ MOUND _ JN GROUND-PRESSURE: SYSTEM-IN FSLI_ tiOLDIhG TANK: RECOMMENDED SYSTEM: (optional)
El S E EJS ClU DS C7U ; ; t,:y ,.~;A : ~ s•
L S _UP LE], S U
_
P . nla?i~ Tests a e N07 reouired DESIaStJ RATE: 5 °."CAM ELtV If 'any portion of the lot is in the
:nder s.H&3.09(5)(.b), indicate: I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
, 5)R1NG1 T6TAL PTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, C JLOR, TEXTURE, AND DEPTH
Ji ER IDEP1, lRi.(ELEVATION OBSERVED 1=ST.TTIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
J.
r„ I qiy ~ r`SJ tFf ~
~y t
i
E
t S.
13-
Z'S
B- / c s r ! 1r t~ l } „x„' rv r
~ i
) B-
PERCOLATION TESTS
TErT pE 7H WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
PJUMBER IN1--(? AFTERSWELLING 1. INTERVAL-MIN. P ico P~Rioo a P R PER INCH
P-
P
P
P-
PLAN VIEW: Show 4oeations 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 percen
a
t Inns{ slop. z j, , i z cr t% s•'vePg S L,t Gri>.6 .t Z.s, :L
SE ELEVATION ,i r /~2
fi t;; !t f1 Afmr t F l / ) E
MAR'
'ter I 1 u/n r - k
i _-T i
e M f ~....._f~ ~i ^z 4
N \
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i, t!-.e undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsir
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief,
INANE (pnnt)` TESTS WERE COMPLETED ON:
i
)'afg' fg 3s
r1DDRESS: _ CERTIFICATION NUMBER: PHONE 14UMBER optional):
J
ICSTSIGNATURE:
DISTRIBUTION Jrigirial'_.~<cuid.uthcrity,~a~~ at;E3ureati>;r'li~tnhin~, page-Soil Tester.
- DILHR-SBD-6395 IN. 03181)