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PRIVATE SEWAGE SYSTEM St. C rCrr:
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INSPECTION REPORT oa:':a "°::rm •,:.:1
1 20 1-9 39 1
GENERAL INFORMATION
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JIS~~ TOWN OF 6,,LaY 04Z- lbito--7Q`2I,
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9~l• la~~-- Darr (e-~
TANK INFORMATION ELEVATION DATA
TY'=_ I::-:1:\U-4CTU~5F. i:A?A°IT' ST!':TI J`. 'Zf -1 F.. -LE
V.
I V
S=Ptit E~i'8h1 l uAc /,000 "senCll-:ar. 111,3 017
i 47p aF Sd~,
a:::ahor, -I 13mg ~91sl.-
I-+olcilnc
TANK SETBACK INFORMATION :::d ct
.en I n.a•:e .511:: IC: Inlet
t c 15a I/ 1 1 Jt 3clttcm
IPloa :Z:a~e
PUMP.'SIPHON INFORMATION
_cww
1'vk,nbi Nunher I
N•83 13.
7 1
l~lldr Fm:
SOIL ABSORPTION SYSTEM
6=l)7R N H.iJ "-f' ie' I-IT 1111 NSIONS !i.m W-•i. IJ _owc GEDCi
M11 NSICINS `s~ J de - - -
TR4 Y 1:="FT=It T:.' F' g-:-:' 4. i _ A.Fi I 4 HIMG Lan'.rr_urc-
Ihi-.eKAi 4TIOh ANREk CIk
xt I ti' t~ - yanll,rl
DISTRIBUTION SYSTEM
1~ Inr
SOIL COVER X press a SVZZ Oolo Xa Mound G, At-Graao Svstvmr onq - -
-lec7 cA.. n.n I?,rf Trn caArc
COMMENTS: i1r1~0!' cone aucrel,_nucs, pc:sa:ls rr=sent. ec. i :r.;pec6or a t~suc-pool R_
Lacabor. dG 11~ /0a p6vNA'A, of '.Su/M~ Cx `sLl.+al
Alt R1e1 le ~.::nFdinf
S ( J ,
31a-s=.'.•:e' 1?optn = L l ~ L1 /t ~
- a'nounl a' cove:. G J(, DQ fl~•C+ a~ d~ COJf~. ~f(; C'Q'
F r~la~ wlu~~~
C4 .,A OCA_
wvl I .l C
.~o. I I I : IC r I II II. Fl PI r Idl _ ` r (V/1 T J
ST. CROIX COITTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
1-his is to cenifv that 1 have inspected the existim, septic and or dose tank
presently sewing the following residence:
(Street address) 'it `t /a 7 17~ located
tit: 5E t411 Section `7 Mown] 1\, flange / W.
Town of L G- . St. Croix County Wisconsin.
Upon inspection. I certify that I htn~e found the tank(s), to the hest of my
knowledge, will conform to the requirements of SPS. 3S4'5. and it (they)
appear(s) to he functioning properly.
Most recent date of' inspection or service 8
I )id flog back occur front absorption system? Yes No
(if no. skip next line.')
Approximate volume or length of tithe: ciallons minuteS
Tank Capacity:
Construction: Prefah Concrete Steel Other
>fanufacturer(itknown): ,aj.-
A,eoffank(ifknown): iSa`t
Permit number (if known) li`1-iW I
(Licensed Plumber Signature) (Print Name)
t, k~~~ j 7 7 / o
(Title) (License Number) NIP MFRS
/Z- zz
(Date)
Fomi to he completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 1,45.06. isconsin Statutes) or licensed disposer
• (NR 113 Wisconsin Administrative Code)
Rev. 220 13
Sftrl - a I& 3 q
J•~~C9 County Sanitary Permit Application ST CROIX COUNTY WISCONSIN
C lq axortl w:tr Cnr:cr. roir. Cun . arias Ordinance PLANNING 8 ZONING DEPARTMENT
Pemo',ta Intormation VOL p ovide may be used for seconda•y purposes S. CP,OU: ; OJN-" u-w°PNIv1 tJ- CZNTE
G• } tPnvaoN Lan ° t5 w' ti 1!0 armichael Road
riudson WI S4C1
- x' ' 51386-4,38. Fay
^1 3dr.-4685
ACa CORI91ele p1an5 IU' ti2 ry'SlC-rl pn 8J- 1 le - 9y 5 < I _r.$ Ir °Re.
COJaly-sal,14 4, Pertnc B ❑ ':`Iezi. I' reuSSi Jf t0 preVi0:1> 2bp k. on
75-416 4) 1 -3
t. Application Information - Please Print all 1 tion Location:
avai-Nainv
SC 14/t E v4 se- 7
vR~~ r(~45r ,2 Q N,
Property Zwne-s Mailnq Address. Lot NumOer Block Numbe-
4 9 V /
State zip ::one (Priam Nane" Supdmsicn Name or CSM NUmDef
RvgERTS W 51 o2 3 71 ' ll~ .S3YS -1g3'74:
It Type of Building: jcheck one; LL.iiy ❑ Village ;97owr of
~K or 2 Farnil-, :hraiinp . Nn r.` s::m =9 1J
N
°ublior,.nmmer:al idre.crihe use; (~/4M1A _
Star=ovmwd Nearest Roan
I.. pe of Pormlt to k only on b::) .r, iin r net:tor. r hne F P appiiabwi ~u. V r-
"sip.-Y ---CL~ r.rer Pamel Via: N:imbers';
..~J U
=P,.onn_dion ❑Non-afimbinc ]Rewvena:.::r i o l o
- .70
Sanitalun . 0-7-d 1j1- 100c,
R, lPermc Numbe• IDatc Issu:.•d
S - ! o - r Y v ,
S:aic Sani:ar' Permc was o:-eviousf\ Issued I I / Ci y (o
IV. Type of PQyVT System: )Check all that apply)
i X Non-aressxized in-wound i ] Morn[ a 24 e'. suitable soil ❑ Mound 5 ir: surablc sot ❑ Ivtound F,--
~`2:and-riEe~ - C Construaey Voetlano ❑ meat FlI:e• ❑ D:i_ Linc
❑ Pressxized. in-ground C Holdrn~7anr, ❑ Sinpie Pass. ❑ Otne,
kr-oraoe C .4mobr l:oata:en: Llnr ❑ Rear_ulatin_c
V. Dislxnsati-Troatment Area Information:
1. Jesion Flow (god 1 2 DISPW :W Area 3. DisPL-rsa. A,L.a 4. Soil A,ccBCavor Rate 15 Perco;ahon Fat 6. Syslern Elecaaon ' . Frna. Grade
y J Repuirec 'ionised !Gnls.:days;.E.) ~i Mir.'in:-tj Eievati0r
11,
Vt. Tank Iniormation Cdpaicly in Gallons Total ? o` 'Janutaclure• Pru`eb Lite Con Steel Fiber. P.astig
ties sting Gallols Tanks Concrete slruclec grass
=xi
Tanks f -anks ~
Vtt. Responsibility Statement
I, the unde sioned, assume responsiDiidq In"eparr: rer:ornenand:reiuvenahun6nstallatiof. o' nor-plumbing for tae aOl4-S shover on the at'acnec plans. A
iiGerise is no: reoutreg for ter-alit., reoal• nr :fie Ir!s3ltat:on of non-plumbing samiatix svisterr..
plumbers Nome kprin'. Pmnbe's sionature in_ stamcst M11ArlRS Nr, Rusiness Phone Numbe•
J,4cYcrl XC-,Ui, 4Zt -•k~~,> ,-.-4~~ ;~)L771 o 7/y - ?4 `C 33%LY
~larnbels Address rStree:. Ccv. State. ZIP Ccde.
v? lI r?E Q< -y e) --:2
VW. County Use Only
San@am .aril- -eF sniff r ant Snr E (IV tarn(J
fG~ 4nprovec Cwne -r (nom 49ver>e }7~ -7
D?t'W",, fi0n `F( 2Z5 . OU /l Z6,
/ V
IX. Conditions of ApprovalfRe/a~sons for Disapproval:
Inn/ t~ Ok ~~,peL o~ /
kez 8:G5
Form- STC-104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~C! `~LF/NC-A)RTrA/TOWNSHIP LU~/f SEC. - 7 T ~N-R ~p 1~
ADDRESS #1W.La v ~ / ST. CROIX COUNTY, WISCONSIN /a
SUBDIVISION ✓ f~l. LOT / LOT SIZE , ~2 f..= S' III
PLAN VIEW
Distances and dimensions to meet requirements of ILHA 83
SNOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1 /
N
r Igky3 sErp~tr l~Eb
vso
~ ZIY'
s
Q45~
p d eo wE~
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used _rPiK~ /K e ToF
Elevation of vertical reference point: wo, O _ Proposed slope at site: _
SEPTIC TANK: Manufacturer: -j~_Liquid Capacity: { Q2
Number of rings used: 3 Tank manhole cover elevation: 9p .
Tank Inlet Elevation:~%3Z Tank Outlet Elevation: 9p
Number of feet from neatest Road: Front
w Side 0Rear, O 11de9 feet
From nearest property line : Front 10 Side,® Rear, O _ ys0 feet
Number of feet frome 1 OT/,N.
building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
OF:PARTMENT OF•INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDING
. LABORS HUMAN RELATIONS DIVISION
P O BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES S APPLICATION
MADISON. At 53707 SIMO PMnID Numher
SO,,NEk,S7,T29N-RIV 174 CONVENTIONAL ❑ ALTFRATIVE Plainug'W'
Toonw]~}. of Warren ❑ Holding Tank In-Ground Pressure CI Mound JJ
`MrAI ~TPFNaPT+IeCBE1T_ - IADDRES i P?WMIT L N: N
Del Weingarten 733 Girard Hudson, WI 54016
ENCHMwRN IPArm,nonl lerereixe aolnD I IFp REN M N. REr. PT.ELEV. . CS L v:
Nam, of PWmpn' -~MPlMPR$W Np.: TGOUnIy. S,nairy Pmma Nunitvr
DDnavin Schmitt 3205 5t. Croix 119461 _
SEPTIC TANK/HOLDING TANK:
MANUrACTLIRFR L*U1DCAPACRY TANKINLEIELEV TANK OUTLET ELEV WARNING LIBEL I HEXING COVER
PROVIDED. PROVIDED
_ YES N YES ❑ NO
171 bFUUING VENT OM. VENT MATL HIGHWATFR NUMBEROF ROAD PROPERTY WELL: BUILDING-. VENTTOFRESN
ALARM FEET FROM IIMF Ain'WET
.
C YES NO O VFS [-]NO NEAREST
_
DOSING CHAMBER:
UI _
~MAnU(ACIUMGR HFODING. l10DCAPACIFY: PUMP A100EL PUMP:SIPHON MANUFACI:IXNR WggNINO LIBEL LOCKING COVER
PROVIDED. PROVIDED
OYES LINO 1 OYES ❑NO DYES ,NO
GALLONS PER CYCLr PUMP AND CONTROLS OPERATIONAL - NUMSEROF JOR OPERTY WELL RUHDIWI WNTTOFRESN
(DIFFERENCEBETWEFN IN ET FROM LINT AIR INLET.
PUMV' ON AND OFFI DYES J NO AREST SOIL ABSORPTIONSYSTEM. Check the soil moisture al the depth of plowing FARCE GTHIIDMMETER MATERIAL AND MARKING
or excavaton.',I' soil can he fulled into a wire, construction shall cease until MAN -1_
tha s0iiis cryeamph to confinue.I
CONVENTIONAL SYSTEM:
BEDITRENCH WNIe LENGTH No Or DISTR. PIPE SPACING,COW R I INSIOFrMe' 0PITS LIQUID
TRFNCHES. MATERIAL PIT DEPTH:
DIMENSIONS
ORA'hl DFP!N FILL DEPTH 21' STR PIPE DISTR. PIPF DISTR. PIPE MA'FRIAI NO DISTR. NLIMBEfl OF isTtOT'Er1 WTLc DT7IC611
UL UW PrvLS AR FIVE COVER. F V MI FT ELEV. END: PIPES FEET FROM LINE AIR INLET
_ NEAREST -111P
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the till material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslopo' mound systems to make certain that it ON REVERSE SIDE. SHOW
U YES LI NO meets the criteria for medium sand. ELEVATIONS MEASURED.
801LCOVER TEXTURE: PERMANENT MARKL HS UBSERVATIONWif LLS.
_ ❑Y_ES]N_OCJ YES O NO _
~DEPIN OVER TXENCHIRFD p[pAI OVER 1XENr,N/BED UEPTKS OF TOPSOLL SDDnFD ,aCCDCD MITI CNFD
ER Foefs
CE. l~
FIVES LINO OYES ❑NO MYES CJNO
PRESSURIZED DISTRIBUTION SYSTEM:
BFp TRENCH MnDTH'. IENGTH NO OF LATERALSPACING :RAVE LCEPTNDELOWPIPF Fn I DEPTH ABOVE COVER
DIMENSIONS 7FENCMLS
MANIFOLD WPELUE' DISTR. PIPE MAN1r-DInMATERML NO OISTA OISTA. PIPE DSTRIBUDOFI PIPF MATERIAL a MARKING
ELEVATION AND II E(FV PIPES DIA.;
DISTRIBUTION ROLE SR E. INFORMATION RRE i:Y COVER MATERIAL VENIK;AI IIFi (:ORgES ND.S TO
APPROKU VL ANS
I~_YES ❑ NO LJ YES l~ NO
COMMENTS: ORSERVATIONWLLLS NUMBER OF PROPERTY WELL FEET FROM LINE
NO LyES ❑NO NEAREST~PL__
U
f~ 3
Sketch System on Retain in county file for audit.
Reverse Side. SIGNAL- ~-l11LE
eD-6710 R. 0&66) iIlp, AIdlIllIllStrator
J ,
ST. CROL COtTS' al~~yQ `3J
12 2018
C ~ERSaI? C F R 1 iC_ =TICi?~ PC F
1, (.a„i. L.-'f 1'1 :-C.~ / /C, ~ ✓ / ~
i'= Licajou -caui : from Pia ninir ,nin_ =i.p i ten: io- nea corsr~c i;,_
Ci , 'ST.--le Pzr.. l 3-:Li anon _Number G V-2 / ~o Z o 0
LF.CAL DESCROTTO\
S--C. 1 N li _ 7k-. T:)-~,Z of
:.t_
Ce: ri5cd Sun e~' \1ap r
~ ~~,iT•- ° -
'Warranty Deed !beft>-e_00?ii'ol'lic - - _ Page
cp baus' G yes C nn Lo: Le< ioea_:nall:e . yes . Lill
' 1YSTEM NI-AINTEN-ANCE AN-D OWNER CERTLFICAFIO.N
mp-c7:'I C ECA~ ~,217._.,an:. Or Y'.1Z coal: - C 1~ L< n^cS3i1 e fti lli'I Ga'i d:t ~c aA. t'-JJ~
-:Ln t_.zna° ~orc:e_c punphe :1z at :ea:il -a, . ' t1-9° • a:: X Li Ll ^rn- z 11xLec_ 7:~pr. Cc ~a:vat: ptt Mt-,
L-~: b°•'si~ID LdL aiJC:a t]t =:ia.'.?:`_ Cf tn:. s^-P5C a, z r, aXunm-, 5:2g, m mt wa:tt d`;pcAal syl:=. LL%'::a:LM2 :x
apolr-:b_:i~cs arc s7n::iu::c is ~SFS. ?F. I': astc in Ciaptz~T C:ah: Counn~ Sa*. ran-.
ne p'.~c^y owlet tom. ees t_ stiesWait L S- Cr `z Co'la'.) k, Zorir._ z ne-c~ratiot f.+-r, si_~c= Mt
-
-•i9- an 'o. z plumb-, ioum'.-N man plumb,-z.. reTi,gt!d piunber o: a :icerset Puma- yc-u, Il t a : i i t o Lin-sitc
e.r~e- = ,~oszl s; men is in a-op_r o~cru n' a_ai oLi Lid or a3& iacps Tor. and pumping i`n ces3 }'j, Call scn5: =7jk if
ea _`;ar.frtil Of Rlut19e.
1'w-,the undersipl d hzve read 3c. a~C`.ye an! a?re :e mam-a¢ tje p:is•ate cea•2et a:spesal Sys-Lem wil Lill
ht~7cin, ar Set by r:ie. DiiPazen: of Safc'~' And ?::+i'CSSienai $~'yl:.CS aad tae D97ar=-n,, c- Na_-UTai
~:a1:' UI LSCByIn. C .Gi1JO:i s CSC hai yni se]ti: ryst.°.n hl L9 Z1L:i:ILi`r_ MUST pe i JlaplM d an_ 7et' °wj i.G lit St. ~_.r.-•I~:
oan:}' ?]anninz L- L:)=-L, rig7al:mcnt -J1?tliz K, d2vs c: ii1C :R'CC %-ar :.y_L-!oIl 73T$.
I-wc :e-t_N Caz: a] .;a_mm's in liic fb= a-: 17ut ua Eat Lb'~o:r. i:rowle_Ce. V"t su%lltet Lht
`lumber of bedrooms _
SICrNA ~_Itic C AF'YL1C ~7,,'; D.!. _ c
s}' jnLf:. mzJon vat is sis- ?resenta_ :natit _ht san a7 :+c-r.it -:V,L-_ b.: L): P':ann:n_ k n¢ r,caz.-zueai
inciud: Ai-I: is app liea'icc a...- ii C i:ll dit 2 L- ;a
re-e.ence is inade in tRFT. OA'1'i