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AS BUILT SANITARY SYSTEM REPORT
31 !
OWNER 1.ckr?.y TOWNSHIP S h SEC .-~QTtN-R ✓SW
ADDRESS f ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION- ~R LO1'-- LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe: VE Str'ck
~
Elevation of vertical reference point: Slope at site: 90
SEPTIC TANK: Manufacturer: ~perS,Y..1✓~____ Liquid Capacity
Number of rings on cover Tank manhole cover elevation:
Wank ~j Ste'
Tank Inlet Elevation: g5.9S Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; Total capacity of
distribution lines- _ 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; _ 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 S. the deptt
_ 13
SEEPAGE 'FRENCH: width length .
PERCOLATION RATE S, AREA REQUIRED _~JS AREA AS BUILT
INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER /sl~~
r
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & 1,,IMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O'. BOX 7969 BUREAU OF PLUMBING
MADISON, WI' 53707
CONVENTIONAL ❑ALTERNATIVE 1,1111, Plan LID, Number
(lf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Larry Hanson RR#2, New Richmond, WI 3- /S-cry
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.
NE NQ, Section 22, T31N-R18W, Lot 3, Northwood, Town of Star Prairie
Name of Plumber- MP/MPRSW No.. County. Sanitary Perm, Number.
Cal Powers 1563 St. Croix 43705
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAP ACITV. TAN K INLET ELEV.. TANK OUTLET ELEV.. IWAR I NG LABEL LOCKING C VY
YES ❑NO AYWI NO
BEDDING: VENT DI VENT MATL HIGH WATER NUMBER OF r ROAD. IPROPERT / WELL. BUI ING
❑ . Al TO FRESH
Z LINE j10
AIR INLET
/ f ALARM
NEARESTOM ~Gw~'l_ <ti~ r
YESNO t(+ ❑YES ❑NO 9
DOSING CHAMBER:
MANUFACTURER BE DDI NG. JLIQUID CAPACI TV PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN El FEET FROM LINE AIR I"LET
PUMP ON AND OFF) ❑YES lNO NEAREST
SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing I FNG7l DIAMETER 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:
WIDTH JLENGTH JNO01 DISTR. PIPE SPACING. COV R JINSIDE DAA nPITS LIQUID
BED/TRENCH TRENCHES M RIAL.. PIT DEPTH
DIMENSIONS r
GRAVEL DF PTH J DEPTH [>ISTH PIPE DISTR PIPE DISTR. PIPE MATERIAL : NO. R NUMBER OF PROPERTY WELL. 13UILDING VENT TO FRESH
BF LOW 'ES,, % E OVER ELEV. INLET ELEV. END PIP LINE AI INLET:
- y FEET FROM R'
2. t NEAREST-s L 7
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-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE IPERMA ANT MAR ERS BS ER VAT ION WELLS
1J YES ❑N ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED = 1 TOPSOIL SODDED SEEDED MULCHE D.
CENTER EDGES.
❑YES:" ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTHBELOW PIP FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL. IND 4nISTR. JD~STRPIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVELEVDIAELEVPIPES DA..
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO L. ❑YES ❑NO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS: MBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE.
t ❑YES ❑NO rElAs ❑NO NEAREST- 4P
C 5
Sketch System on etain in county file for audit.
Reverse Side. ! i
SIGNATURE TITLE.
DI LHR SBD 6710 (R. 01 /82)
mmmmilimm wlsconsln APPLICATION FOR SANITARY PERMIT
D ILHR (PLB 67) COUNTY
~ oeaRRTmEn'r of UNIFORM ~SyANITARY PERMIT #
InoUSTRV,LRBOR 6HUmRn RELRT1on5 Al { w
-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 MAIITING ADDRESS
PROPERTY LOCATION CITY:
VILLAGE:
1/4 `/1 1/4, S-:'_,? . T~' . N, R V (or) W TOWN OF:
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.
EJ 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
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Pritit): Signatuf6 I MP/MPRSW No.: Phone Number
71
) 1!i.~v`!
Plumbyr's Address: (r Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
,~v❑ Owner Given Initial 1,2 &146y f1 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.
Form - S T C 100
owner of Property ~11,
Location of Property Section. ,'P1 N R __`h' W
Township-- .X }
Mailing Address
Subdivision Name
_1
J7
Lot Number_
Previous Owner of Property ,
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? Yes No -
Include with this application one of the following:
.-'.Certified Survey Map
.Deed
.Land Contract, or
.Other Vagal Document which describes the property
I
PROPERTY OWNER CERTIFICATION 'Il
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 warranty deed recorded in the Office of the
County Register of Deeds as Document No. _-4 ; 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 D~ Is, s Document No.
SIGNATURE 7"W"" SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE 51 ED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS 1 / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION:, SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.=SUBDIVISION NAME:
1/4 /T-- NCR ,
COUNTY: OWNER'S/BUYERS NAME: MAILING ADDRESS:
i
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
El Residence ONew ❑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)
[:Is ❑u ❑s ❑u ❑s [:]U [:]S J
[]U ❑s ❑u
If Percolation Tests are NOT required DESIGN RATE: ,
I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: ^ ! i J, Floodplain, indicate Floodplain elevation: 1i
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, ^AN DEPTH
NUMBER DEPTH H4, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
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 -
i
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 elution at,-all borings and the direction and percent
of land slope. Ji7r lrr.,ID
f.J
SYSTEM ELEVATION 1f
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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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST, NATURE:
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