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1 Y
AS BUILT SANITARY SYSTEM REPORT
4
OWNER', di TOWNSHIP `SEC . T N-RNW
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
,i
RL"----V1EW -_r
Distances and dime ns tq meet requirements ot.H63
rs
SH VERYTHING WITHIN 100 FEET OF SYSTEM
t
I J
1 i / \
I di at N pr h rr w
EEcBENCHMARK: (Permanent reference Point) Describe: oi~ a s/~~~ oJS~~P
Elevation of vertical reference point: z&/ zi Slope at site:
s
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover ank manhole cover elevn: -
Tank Inlet Elevation: % p Tank Outlet Elevation: RA
PUMP CHAMBER /
Manufacturer Number of gallons hf~
Number of gal. pump set for /4'1cycle gallons, Total capacity of
distribution lines i Sf gallon: size of pu p ~Q head;
gallon per minute horsepower I ;brand name of pump
and model number ;
Type of warning device x. -
HOLDING TANK: Manufacturer Number of gallons
Eleya/t.4on. 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.
SEEPAPE BED SIZE: number of lines.- width _length ~tile depth
SEEPAGE TRENCH: wid h length
PERCOLATION RATE AREA REQUIRED ^ AREA AS BUILT
INSPECTOR
DATED= PLUMBER ON JOB
LICENSE NUMBER
en::fayef+~q,ae.:o'HaaM'-u4-,wrv<MS'- F^°""•••..
.wr... n+mr .w.-wMrts<.opYi.MC'[:.:.rYtwtM
AS BUILT SANITARY SYSTEM REPORT
1
OWNER TOWNSHIP _ SEC. T N-R W
ADDRESSST. CROIX COUNTY, WISCONSIN.
f' K i
SUBDIVISION LO'T LOT SIZE
PLAN VIEW
Distances and dimor~s_i.9ns to meets requirements of H63
SII&W EVERYTHING ;WITHIN 100 FEET OF SYSTEM
J
_i I di at N r h rr w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point:,!]/ i _ Slope at site:- ~SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover `lank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER / i
Manufacturer: Number of gallons
gallons; Total capacity of
Number of gal. pump set for a 'cycle
- -
distribution lines gallon: size of puulp_i_ head;
gallon per minute horsepower ,brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer- _ _ _ Number of gallons
Eleva; on of manhole cover J;
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: number of lines width length,- the depth
SEEPAGE 'TRENCH: width Iength-
PERCOLATI)N RATE AREA REQUIRED AREA AS BUILT <.;
INSPECTOR
DATE'L) - PLUMBER ON JOB /
- - - - - _
LICENSE NUMBER
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 79969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MADISON, WI 53707
E~CONVENTIONAL ❑ALTERNATIVE State PlanLD.Number
(If assigned)
Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE
Dean Bettendorf RR#l, Somerset, WI
k 'V-S
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV..
SW SE Sec. 7, T31N-R18W, Town of Star Prairie
Naine of Plumber_ MP/MPRSW No
County. Sanitary Permit Number:
Cal Powers 1563 St. Croix 38540
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. E-Al'? CITY. TANK INLET ELEV.: TANK OUTLET ELEV. . WARNING LABEL LOCKfNVER
PROVIDEDpq z C1 C' ]YES ENO FENO
BEDDING. VENT DIA.. VENT MATL. NUMBER OF ROAD: PROPERTY WELL. / BUILDING. ]VENT TO FRESH
FEET FROM LIN ET .
DYES ENO Z_ C O NEAREST
DOSING CHAMBER:
MANUFACTURER . =BEDDIIN LIQUID CAPACITY TV EL PUMANU ',T IiH ER WARNING LABEL LOCKING COVER
P IDEDP IDEDU v,v~C-.~ YES ENO YES ENO
GALLONS PER CYCLE: / PUMP AND CONTROLS OP ;.T-AL. NUMBER OF PROPERTY WELL B~LDJNG VENT TO FRESH
(DIFFERENCE BETWEEN] FEET FROM AI w r
l1 f
PUMP ON AND OFF) YES ENO _ NEAREST T+-`~ • ~ ~f '
SOIL ABSORPTION SYSTEM. Check the soil moisture at th depth of plowing LENGTH 1111AMITIH JMATERIAL 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:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVE'S NSIUE DIA JFPITS LIOUID
DIMENSIONS ~2 G H TRENCHrs MAT alAU PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. ISTR NUMBER OF PROP ERTV ;70~% DING VEN T TO FREBE LOW PIPES ABOVE COVER EI EV
INLEL V END AIR
PIPESLI FEET FROM LINE
LET
2 -7NEAREST-•. ?C~ A r
MOUND YSTEM:
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-
DYES ENO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PEHMANE>; RKERS. OBSERVATION WELLS
r Y J ENO EYES ENO
DEPTH OVER THE NCHBED DEPTH OVER TRENCH;BEO DEPTH OF TOPSOIL SOD D SEEDED MULCHED
__J
1CENTER EDGES
❑Y S NO EYES ENO DYES ENO
PRESSURIZED DISTRIBUTION SYSTEM: f
BED/TRENCH WIDTH ENGTH NO.OF LATERAL SPAc ING G VE DE H BELOW IPE FILL DEPTH ABOVE COVER
TRENCHES.
DIMENSIONS tr
MANIFOLD PUMP MANIFOLD DISTR. PIPE NIFOL eM TERIAL. N DISTR DISTR. PIPE DIST HIBUiION PIPE MATERIAL & MARKING
ELEV.'. ELEV.. DIA ELEV.'. P ES'. DIA.:
ELEVATION AND
,DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER AT
RIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
EYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTTLL~
BUILDING.
FEET FROM LINE
r~ DYES ENO DYES ❑N NEAREST
Sket
System on Retain in county file for audit.
Reverse Side.
SI GNAT UR E.
TITLE.
DILHR SBD 6710 (R. 01/82)
Wisconsin APPLICATION FOR SANITARY PERMITS
(~IDILHR COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
nE5 RR -MEnT OF
InUUSTRV, S0R & HUMRn RELRTIOnS
-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 MAILING ADDRESS
PROPERTLOCA ION CITY:
VILLAGE:
1/4 1/4, S % T'-" , N, R ! (o0(W TOWN OF: J x,
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
r~
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.
2 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: c7
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
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print,): Sign r MP/MPRSW No.: Phone Numb.
r /
Pfumber,s Address: % Name of Designer: i
/4t 1
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: [Fee: Date: ❑ Disapproved
1 ❑ 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 j
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.
r-°
Fornl - ST C 100
Owner of P r o p e r t y
Location of Property A/W ' SE 'j„ Section_ 7 T i NCR W
/!,u/~ LV 1- oi-'S~ SECTios✓ 7
r township STK 7-3 / /V.
Mailing; Address "f 25~
SGZ f`? ~ G T u✓t ~ ~ Cr ~Z 7 -
Subdivision Name
Lot Number ~q
Previous Owner of 1?roperty.2-F,4ti -6/-/`9'EKT~w L.
15~TT~.dyc, ~F
Total Size of farce]. '6 6
Date Parcel Was Created
-7LAre all corners identifiable? X Yes No
Include with this application one of the following:
Certified Survey Map
.Deed
.Land Contract, or
.Other Jvegal Document which describes the property
T~ x ~iPTs
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 warrant=dispos&1-W9tem Office of the
County Register of Deeds as Document that I (we)
presently own the proposed site for the s(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 OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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DEPARTMENT OF REPORT ON SOIL BORGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
DIV ION NAME:
UB
LOCATION: SECTION: TOWNSHIP/M1dNICtPA-LITY: LOT NO.:BLK.IVOT
/T N/ ~ f (or) W , r
C9,UNT OWNER'S/BUYER'S NAME: MAILJNG ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: Cl COMMERL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence [Z New ❑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)
Qs ❑u as ❑u ®s ❑u ❑s ~u asu
If Percolation Tests are NOT re uir DESIGN RATE:
q I If any portion of the tested area is in the /
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
9
B- Z
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PE D 2 PE OD 3 PER INCH
P- / i
P-
-30
30
P_ :N
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. s P) q
SYSTEM ELEVATION
J a
, c 1 1
1 €
I ~
~ t
t E
{ )
ke
,
E
{
G
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 (13/int): TESTS WERE COMPLETED ON:
ADDRES i CERTIFICATION NUMBER: PHONE NUM ER (optional):
CS ~ GN TUREt
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:
' PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
Vent Cap Weather Proof
Junction Box Approved Locking
Manhole Cover
12" Min '
4" C.I. '
Vent Pipe Final 4" Min
Grade '
Conduit
18" Min 1 18" Min
Inlet
Approved Approved
Joint w/ A Joints w/
C.I. Pipe C.I. Pipe
Extending Extendin g
3' Onto ; ;'eq6Alarm 3' Onto
Solid On B Solid
Ground Ground
C
Pump - 4^-~ Of f
Concrete Block D
SPECIFICATIONS
TANK PUMP
Manufacturer Manufacturer: Tank Material: Model Number ;~1 U) f _ ,jam
Tank Size: Gallons Switch Type
Total Dynamic Head: FT
CAPACITIES Pump Discharge Rate: GPM
Total Daily Effluent: Gallons
A or Gallons Number of Doses: ~7 Per Day
B = or Gallons Dose Volume: j~-7 Gallons
C " or j' Gallons Notes: 1. See pump curve for
D or Gallons additional performance
Total Tank information.
Capacity Required Gallons 2. Pump and alarm are to be
installed on separate circuits
ALARM as per ILHR .19 WAC.
Manufacturer: SIGNED:
Model Number: LICENSE NUMBER:
`
Switch Type i~, as ,:'==%f+ DATE:_
.Model 3870 Submersible Effluent Pumps
140
120
~A
's
100 y'o
0
LL
a 80
m
ar
~pAY7S
E • 7~
~ HA
o I'vphjo
Jiyp
60
H ~Vp
~~1 a
_ 'hp
A
40 wpN05, AY .P
WPM03, Y, H.P.
20 WP03, h H.P.
i
0 20 40 60 80 100 120
Capacity - Gallons PWMinute
Max. wt.
H.P. Order No. Volts Ptuse Amps RPM SdWS (Ibs.)
E. WPO311E
WPM0311E 115 9.4
1750 56
W P0312E
WPM0312E 230 1m 4.7
1 £ WPHO511E 115
WPH0512E 230 8.0
WPH0532E 208/230 3.4 60
- WPHO534E 460 3m 1.7
WPH0712E 230 10 9.0
WPH0732E 208/230 54
WPH0734E 460 3m 2.7 70
WPH1012E 230 10 11.6 345Q Y.-
1 WPH1032E 208/230 64
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WPH1512E 230 10 13.3
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1,h WPH1534E 460 3o 4.6 80
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30 WPHH1534E 460 4.6
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Parcel 038-1030-40-300 01/24/2007 03:22 PM
PAGE 1 OF 1
Alt. Parcel 7.31.18.141 B-10 038 - TOWN OF STAR PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
DEAN BETTENDORF O - BETTENDORF, DEAN
852 220TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 852 220TH AVE
SC 5432 SOMERSET
SP 1700 WITC
I
Legal Description: Acres: 19.990 Plat: 4357-CSM 16/4357
SEC 7 T31N R1 8W NW SE SW SE LOT 2 CSM Block/Condo Bldg: LOT 2
16/4357
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-31N-18W SE
Notes: Parcel History:
Date Doc # Vol/Page Type
07/02/2002 683339 1921/563 WD
2006 SUMMARY Bill Fair Market Value: Assessed with:
174801 256,300
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
UNDEVELOPED G5 6.990 10,000 0 10,000 NO
PRODUCTIVE FORST LANDS G6 11.000 44,000 0 44,000 NO
OTHER G7 2.000 25,000 147,500 172,500 NO
Totals for 2006:
General Property 19.990 79,000 147,500 226,500
Woodland 0.000 0 0
Totals for 2005:
General Property 19.990 79,000 147,500 226,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 568
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00