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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
L4BOfR & HUh'.AN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BvX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan L
O H ID.Number.
6 ssigned)
ding Tank ❑ In-Ground Pressure 1:1 Mound ( a
NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER: INSPE jN DATE.
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. RE E. PT. ELEV.: ST REF.-PT . ELEV.
S~J SECT/O~ / 7 G1 p fdd
N11. f Plumber, JMP!MPRSW No.. County Sanitary Permit Number.
SZ- '9
ze4&9 EM
SEPTIC TANK/HOLDING TANK:
MANUF gGTDR R'. LIQUID CAPACITY. TANK INLET~ ELE~ V TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
V L" V ^ PROVIDED'. PROVIDED
/i~ :
YES ENO DYES ENO
BEDDING: VENT CIA VENT MATL.. HIGH WATER rNNO UMBER OF ROAD- 1PROPERTY IWELL. BUILDING. (VENT TO FRESH
p/ ALARM EET FROM LINE if AIR INLET
YES ENO / ~r~,J ~ DYES EEAREST /L/ ~ 4
DOSING CHAMBER:
MANUFACTURER JBEDDING. LIQUID CAPACITY PUMP MODEL PUMPi SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED:
EYES ENO DYES ENO DYES ENO
GALLONS PER CYCLE: FPAND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
JIE AIR INLET.
I
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing v l I~ - Uln%11 TER 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:
INIDTIj LENGTH NO. OF T~~' S ACIN(, COVER P DE DIA'PITS LIQUID
BED/TRENCH TRENDEPTH
DIMENSIONS I
' ~ ~/Cfi3l('
PROPERTV WELL. BUILDING: VENT FRESH
(;Fill" I I .1'111 FILL DEPTH IIV PIPF TR. PIPE DISTR. PIPE MATERIAL. NO. DISTH NUMBER OF ~T A
k h I ! ti S ABOVE COVER ELEV. INLF r Eft' Of ~f PIPES 1 LINE IR INL LET.
FEET F
/ ac f ! • A e ~ to • ~ ~ NEARESTO--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-
meets the criteria for medium sand. TIONS MEASURED.
DYES NO
SOIL COVER. TEXTURE PERMANENT MARKERS. OBSERVATION WELLS
I DYES ENO DYES ENO
DEPTH OVER TRENCH HFD DEPTH OVER TRENCH. BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
CENTER EDGES
DYES ENO DYES ENO OYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NLATET DEPTH BELOW PIPFFILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTMATERIALNODISTRJDISTRPIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVELEVDIAELEVPIPESDIAELEVATION AND
DISTRIBUTION
IIOI E SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIALVERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
DYES DYES ENO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: =NE OF PROPERTY WELL: IBUILDING
FEET OM LINE.
E YES ❑ NO DYES ❑ NO T
Sketch System on Retain in county file for audit.
Reverse Side.
.
SGN T R~{E TITLE
DILHR SBD 6710 (R. 01/82)
State and Coun State Permit #
PLB 6 7 Permit A licati UN 1982 County Permit # T~
for Private Domestic Sew ystemION/NG County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required n #
G
A. OWNER OF PROPERTY Mailing Address:
t r r u i u 5'6 n G I
B. LOCATION: L_'/4 to%, Section 7 T 2e N, Rq 0 (or) WILot# City
Subdivision Name, ( nearest road, lake or landmark BIk# Village
l u N V Township v G✓~ v)
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY ~c -Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete -Ll"" Poured-in-Place Steel Fiberglass Other (specify)
New Installation V Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area-12197
sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: o in pal Ft. i h Depth Tile depth (to) No. of Trenches
Seepage Bed: Len tg h 3 Width Depth Tile depth (top)~:S1~.No. of Lines
Seepage Pit: Inside iami epth No. of Seepage Pits
Percent slope of land Distance from critical slope
',MATER SUPPLY: Private Joint ❑ Community ❑ Municipal El
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Ter, l f_
NAME Pr"tim r 9 /24 (~l~r y ~C/! 11/4 ^11 C.S.T. # 7 Y and other information
obtained from 1; ^ - (owner/bull pry
Plumber's Signature en P/MP- SW # 6j_fr' 3,Z- Phone # 2~ 3 Z
Plumber's Address u , c i~ 5
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Belovy FOR COUNTY AND STATE DEPARTMENT U E ONLY
Date of Application y'Fees Paid: State County Dat
Permit Issued/ft a (date) (n Issuing Agent Name
Inspection Yes No State Valid# Date Recd
1. county (white, copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
JFPARTM[NT OF
p BORINGS ,7
INDUSTRY, L~ O OR~ ~ SOIL ND SAFETY B DIIVISION
LABOR A'ND, P.ORQX 7969
HUMAN RELATION PERCOLATION TESTS (115) MADISOPJ, WI13707
I-0- _r -,A ~ TIQN. MV, OW SHIP/M NIOIPArL-14TH ' LOT :BLK.NO]SUBDIVISION NAME:
COUNTY: Oip/0t`STdDVIS NAME: MA _
USE DATES OBSERVATIONS MADE
_ NO. BAD 00MMEACIA~D 1 PITbTTC7` 6ESZ`FiTP 1 i6N9:C0CA~-°TZ,Tv'f~SrT`Sl
°~Residence R-tt ~ QNew ❑Replace `
11 _ _1
MATING: S= Site suitable for system Us Site unsuitable for system v'
uNVFNTIONAL MOUND: IN-GROUNDPREUR E: SYSTF_M-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
]SEu1as_au~_c1sE 111Sau ❑s❑u
DESIGN FtA7E; SYSTEM EL~Q.
n h s~lHfi3r0915)s ire Nor r q i,, rt,l t I If any portion of the lot is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
ioRING~TOTAL Ej_HT0 R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
JUMBER DEPTH IN. ELEVATION OBSERVED EST. 6IGHE- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK,)
B_ / ✓ Ar l.N ! t!r p 4 F w r i~ 1" Y li ! l r' i rm ` F 1 A
I l
B_ J♦ p M A'1'
_B-
B-
Y[[ /i } / d ~I 41 t , e y I l~ ' / / t 1 ENV 4 , s
8_ t Pf ~r~..A'✓' f (r;a,/r /'~i°. A Ar (r"~L./ Rr _ '~t~ -fir ! -
LB.
PERCOLATION TESTS
TEST DEPTH A ER IN HOLE. TEST TIM E 5ROP IN WATER L_-V L- HES RATE MINUTES
NUMBER INCHES AFTf RSWFLLIN INTERVAL-MIN. l D PF 105-1 PER ER INCH
3" / r }s,_ y ta - t~QQom- 1'F .t,,
lie-
P.
P- .
P-
PLAN VIEW: Show locations of percolation tests, soil borings and'the dimensions: of suitable soil areas. Indicate scale or distances. Describe what are the hon-
Pontal and vertical elevation reference pointill,and show their location on the plot plan. Show the surface olevstion at all borings and the direction and percent
of land slop.
SYSTEM ELEVATION
I °A
r y~yyy,I G
04, 1 14v
I'N
40~ 70'..
41 J~
I
I
a I
I
14
e
i P I is
I, the undersigned, herebv certify that the soil tests reported on this form were made by me in accord with the procedures meUn,dk sne the Wisc-,
f,dmimistrative (rode, and that the data recorded and the location of the tests are correct to the best of my knowledge and behat
A MED pn nt;. TESTS W ERE -CO M-1 r '
__--------CERTIFICAT!
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SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 22878 PAGE 1
08/28/92
St. Croix County Zoning DATE COLLECTED: 08/19/92
911 4th Street DATE RECEIVED: 08/21/92
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE DRINKING WATER
Attn: Mary J. Jenkins
SERCO SAMPLE NO: 76022
SAMPLE DESCRIPTION: McDonald
ANALYSIS:
Bromodichloromethane, ug/L <0.2
Bromoform, ug/L <0.5
Bromomethane, ug/L (Methyl bromide) <1.0
Carbon tetrachloride, ug/L <0.2
Chlorobenzene, ug/L <1.0
Chloroethane, ug/L (Ethyl chloride) <0.4
2-Chloroethylvinyl ether, ug/L <0.4
Chloroform, ug/L <0.5
Chloromethane, ug/L (Methyl chloride) <0.6
Dibromochloromethane, ug/L <0.4
(Chlorodibromomethane)
1,2-Dichlorobenzene, ug/L <1.0
(o-Dichlorobenzene)
1,3-Dichlorobenzene, ug/L <1.0
(m-Dichlorobenzene)
1,4-Dichlorobenzene, ug/L <1.0
(p-Dichlorobenzene)
9
Dichlorodifluoromethane, ug/L (Freon 12) <0.5 !d
1,1-Dichloroethane, ug/L <0.1
G 3
1,2-Dichloroethane, ug/L <0.2 r►
(Ethylene dichloride) 4,~
ca
1,1-Dichloroethene, ug/L <0.2 ~ O ivE
trans-1,2-Dichloroethene, ug/L <0.1 0 ~g w
1,2-Dichloropropane, ug/L <0.1
cis-1,3-Dichloropropene, ug/L <1.5
trans-1,3-Dichloropropene, ug/L <0.9 g
< means "not detected at this level". 1 mg = 1000 ug.
MEMBER
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 22878
08/28/92 PAGE 2
SERCO SAMPLE NO: 76022
SAMPLE DESCRIPTION: McDonald
ANALYSIS:
Methylene chloride, ug/L <5.0
(Dichloromethane)
1,1,2,2-Tetrachloroethane, ug/L
Tetrachloroethene, ug/L <0.2
1,1,1-Trichloroethane u <1.5
' g/L <5.0
1,1,2-Trichloroethane, ug/L
Trichlorofluoromethane, ug/L (Freon 11) <0.7
Vinyl chloride, ug/L
Benzene, ug/L <1.0
Ethylbenzene, ug/L <1.0 '
<1.0
Toluene, ug/L
Trichloroethene, ug/L 2.5
2.5 ~
-WA a/
This sample's analytical results (ii;)
SDWA Maximum Contaminant level of 01/3p/g below the U.S. EPA's
compounds which are also on the SDWA MCL list. se requested
< means "not detected at this level". 1 mg = 1000 ug. kd:-:y
f~
q
MEMBER
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 22878 PAGE 3
08/28/92
All analyses were performed using EPA or other accepted methodologies.
Samples that may be of an environmentally hazardous nature will be
returned to you. Other samples will be stored for 30 days from the
date of this report, then disposed of by SERCO Laboratories. Please
contact me if other arrangements are needed. This report may not be
reproduced, except in its entirety, without prior written approval
from SERCO Laboratories.
Report submitted by,
/IZ DL l ~
Diane J. derson
Project Manager
< means "not detected at this level". 1 mg = 1000 ug.
a r S;
tvn
MEMBER
r
G / ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
l
Telephone - (715)386-4680
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion of this form is essential ag that tag praperty can be
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING----------------------------FEE: $ 35.00
(For nitrates and coliform bacteria)
WATER TESTING FEE: $185.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00
(Determines if system Is properly functioning at time of
inspection)
l' J1 ✓i I Y'~ /U fr
PROPERTY OWNER'S NAME:
PROP. ADDRESS : ' `I CITY ` r
Legal Description 1/4 of the 1/4 of Secti_oq (N-R~_LC
Town of Lot Number Subdivision: 1 l l
FIRE NURSER ti ) LOCK BOX NUMBER
Color of house,','- Realty sign by house?-IL✓.,If so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services: '
Telephone Number
REPORT TO BE SENT TO:
r _
CLOSING DATE:
Signature