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ST. CROIX COUNTY ZONING OFFICE
c~ - St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
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 ia essential aQ that 11m property fan bg
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 f
(Determines if system is properly functioning at.-time of
inspection)
PROPERTY OWNERS NAME lr
PROP. ADDRESS: `,At CITY
Legal Description lCt/ 1/4 of the 1/4 of Section , T N-R~
Town of Lot Number Subdivision:
FIRE NUMBER LOCK 13OX NUMBER
Color of house Realty sign by house? If so, list firm:
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PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF TILE 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: :y-
Telephone Number
REPORT TO BE SENT TO: w c_~ 1 .7Ci C~ =-Fd C`
CLOSING DATE:`
Signature
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ST. CROIX COUNTY
WISCONSIN
4 k'a41~ ZONING OFFICE
`r a ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
July 1, 1992
Andrew Germain
2026 Co. Rd. C
Somerset, WI 54025
Dear Mr. Germain:
An inspection of the septic system on the property of Andrew
Germain, located at 2026 Co. Rd. C, Somerset, WI was conducted on
June 30, 1992.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
.there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
(in erely,
James K. Thompson
Assistant Zoning Administrator
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0. ADDRESS ST, CROIX COUNTY, WISCONSIN.
:3DIVISION S C S~.
LOT LOT SIZE
PLAN VIEW ~`/~ll~rry S
-Distances & dimensions to meet requirements of H62.20
y SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /o
a t ri 'l~
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-TIC TANK(S) 1 MFGR.< CONCRETE STEEL
NO. of rings on cover Depth_ DRY WELL
'NCHES NO. of width length area
no, of lines width 7 length area
depth to top of pipe `
,2E GATE
-a RATE AREA REQUIRED AREA AS BUILT
'Ciaimer: The inspection of this system by St. Croix County does not imply complete j
pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
tem operation. However, if failure is noted the County will. make every effort to
ermine cause of failure.
:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
BATED PLU,%MER ON JOB
LICENSE NUHBER~
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sani taAy Pe.Amit
State Septic
AME Towns hi p St. CAOcx County
,cation hk) 0 . Section076 Lot Subdi vision
EPTIC TANK
S t ze,(.0 O O gattonz Numb eA o j compan.tme.n"
5 ta.nee 6nom:. Wett Building 2 _L1.2 p tape
Hi hwa.teA ' - Out S. e- r-% o~ ec~rcJeb
:aMPlNG CHAMBER me L uric
Size ga.E.bon4,Pump Manu6ae-tuae4- Mode.E NumbeA
i)LDING TANK
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Size 9axton4- Numbed. P6 CompaA menu
Pumpe.A AQatm System
f6.tanee. 640m: Wet Building 120 stope
Highwa.teA'
-;SORPTION SITE
BedsTAeneh
titanee. 6AOm: Wett 8uitding 12$ btape
Highwa.teA
;SORPTION SITE DIMENSIONS
W4' doh o4 tAeneh 6t Req ui4ed anea
Length o6 each tine 6t Depth 06 uck below -tile in
Numbers 06 tines 2 Depth o6 Aock oveA tite tin
To ta.e Ce.ngth o4 tines ' 2- 6t Depth o6 ^tite b etow gAade in
Die.tance between eine.66t Stope 06 atneneh kn, pen 100 6t
Y
f 4«1 a(,1su&p ttion anea (,7 4 6,t Type o6 CoveA: PapeA o .6 tAaw n
IT DIMENSIONS-
Numb e.n o6 pits / GAavet akound pits yes no
Outs de diam /le
eterc 6t D'epth b etaw in.Eet
6x
Totat abaoAp.t.ton anea;/ 6t
AAea AequiC Led 6,t
v S P ~.T+V D TITLE
PROVED DATE 19 8.(
c JECTED DATE 198
JASON FOR REJECTION -
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REPORT ON INSPECTION OF SANITARY PERMIT # ~-2 %S z1
(1) Name and Addre s of Permit Holder Person/Persons at Site (2 )Date of Inspection
Time of Inspection
ame, r ss, cense No. o iinstalling Plumber
1 1-33 I TALLATION CONSISTS F: ❑ Septic nk ❑ Seelpage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
(4)BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired'? ❑ YES ❑ NO
8 HOLDING TANK: Manufacturer o gallons
construction depth to the cover ft; If septic tank is
being used are baffles removed? ❑ YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO
(13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR-SBD-6095 N.05/80
Signature of Inspector:
State and County State Permit #
PLB 67
Permit Application County Permit # ~
for Private Domestic Sewage Systems County Z L l
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
A A ~ /l,T,Z 4, ti
44 IV Wl-? B. LOCATION: iV VV'/a '/a, Section , TZI N, R E (or) W Lot#' City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township e
C. TYPE OF OCCUPANCY: *Commercial *Industrial Other (specify) *Variance
Single family_ Duplex No. of Bedrooms _ No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete` Poured-in-Place Steel Fiberglass Other (specify)
New Installation/ Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete -Poured-in-Place Other (Specify)
E. EFFLUEN . DISPOSAL SYSTEM: Percolation Rate LL' ! Total Absorb Area-Q-sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width DApth_ Tile depth (top),,_ No. of Trenches
Seepage Bed: Length 3'-*? Width Z.1 Depth Tile depth (top),v~No. of Lines °Z
Seepage Pit: Inside diame;lier. Liquid Depth No. of Seepage Pits
Percent slope of land. 1 %o /V Distance from critical slope- R e
WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑ ~/y 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 Certif e Soi! Tester,
NAME = C.S.T. # _ and other information
obtained from , j (owner/builder).
Plumber's Signature MP/MPRSW# _l f 37 Phone
Plumber's Address 4t-i~e- ^1
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 Below FOR COUNTY AND STATE DEPARTMENT USE_ ONLY
Date of Application Fees Paid: State . ' ; C ( County e e Date 0-
Permit Issued/ Rejected (date) 1 - S` _Issuing Agent Name = d
Inspection YesX__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
EH 11.5
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: Section cZ11, T:~(N, R Mo(or) W, Township or
Lot No. , Block No. -County
/ p ~ Subdivision Name
Owner's Name: 1.-t1 j-)) rU I- ova al
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Mailing Address: ~ZP} ;3 7 e iS 4r-
TYPE OF OCCUPANCY: Residence No. of Bedrooms _ Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS Cfi •T 7,S PERCOLATION TESTS C~ rr =3 i
SOIL MAP SHEET SOIL TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-
P-
P_ ~
1
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
I
72 Z_
72 7 Z2
77-11 4'e, ic r
71_ /C Z r- -
S.
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of $-uiTble areas. Indicate number of square feet of absorption area
needed for building type and occupancy. i L ~y ,!h',10tiE Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief.
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Name (print) `'/4-`'"` 1, - '~"~f`l f' l C ificat'pn No.
Address
Name of installer if known
CST Signaturq ~
LOCAL AUTHORITY
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