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HomeMy WebLinkAbout030-1092-70-000 Wiscon 'sin Department of Commerce Count y PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 363527 Permit Holder's Name: ❑ City []Village ❑ Town of: State Plan ID No.: Betker Ernest & Lynn St. Joseph Township CST BM Elev.: Insp. BM Elev.: BM Description: cel Tax No.: fl 1 tO n �sT Par 3 ' ' 030- 1092 -70 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic LZS"0 Benchmark �, �� c(. , ' �7D • O ' Dosing Alt. BM , 9( 2 Aeration Bldg_ Sewer - 7. - ?p c �,8 ,c r 0 9 Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet ir Septic O Z ' NA Dt Bottom -- Dosing NA Header/ Man. Aeration NA Dist. Pipe 14 9.9 . zs Holding Bot. System L II• C 4. 5'03 D. Z. PUMP/ SIPHON INFORMATION Final Grade s; u w- 98 Man cturer De St cover s.6 ( J .0 Model Number GPM TDH Lift Fri S stem TDH Ft Forcem Length Dia. To well SOIL ABSORPTION SYSTEM �Z ffWqRENCfj> width Length , No. f enches PIT No. Of Pits Inside Dia. Liquid Depth DI MEN �J S DIMEN I N Manufacturer: b� SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Vero INFORMATION Type O r / CHAMBER M el Number: System: � ' . � D 6 OR UNIT �i — o, c c DISTRIBUTION SYSTEM Header /Manifold u Distributi e(s) x Hole Size I x Hole Spacing Vent To Air Intake Length Dia. Length Sia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: DZ/Z( /C'binspection #2: — Location: 1212 Trout Brook Road, Hudson, WI 54016 (SE 1/4 SE 1/4 31 T30N R19W) - 31.30.19.339 1.) Alt BM Description= 2.) Bldg sewer length = o19 - amount of cover = u n re ' o quired? E] Yes No Use o t information. o$ o z o o ( _G �( SBD 710 (R.3/97) &A� Date Inspector's Signature Cert. No. re ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E ° . f n me x C £ 3 ®m i E L 3 ¢ i r a 3 g �x i r 3 E d } 3 � ° a a i a „ e E � r 3 p o .m ..,,. .. ..e... . » .......... .. . e...m .. _ ._ , ,« _ e, j g E i f E i t Pe = e a e ,,,. ,. .,.� ... e• ... e <a-.._ .., st< oae�m. .�amm .a. e. .i�.m- _ >., _ .... __ m® T 3 m a 3. ..e r^-. a »a dma .m,ma.,...m v.e .. a.� m. m . , o- . e..m. e =, ..,...e. _ -.. .ve ,°€... _,, .... _ ,. � .� e 9 } ' y, E � i .,A.. _,., .�. ...,. ..�... .. , m .,. -. ...e ems.. 3 s ; e x � z m m � T � e ° ro F i ° e 3 E e 3 3 e f t i r 3 t " r } r E e i e i I j E S t E e } x 6 , ,:'r , ., .. E } .,,.,...,.mod _...... ... � � ..... .... . . . .... .�..... _..... ....,.:. _ ,. _. ... .. ..... _ >. W s f E a z e f r e € l t ` � S V ' . :LL - - _. 1 , "l7 a { , - , 1 ' ,gyp O I ; 1 3 � /217- _rgOAA.�&4,W 20 �, Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 2 1 B. Washington Avenue Department of Commerce In accord with ILHR 83.05, W' iC r 1 Madison, WI 53707 -7302 -_P • Attach complete plans (to the county copy only) for the sy n pa ern t less, 111 unty than 8 v2 x 11 inches in size. r C� r A • See reverse side for instructions for completing this app c ati on , "` % Sta Sanitary Permit Number - 316 3 82�- Personal information you provide may be used for secondary purposes O C eck if revision to previous application [Privacy Law, s. 15.04 (1) (m) - `' 5t a Plan I.D. Number rq� �, I. APPLICATION INFORMATION -PLEASE PRINT AL k11P ON Pro Owner g ame �+ 1 P op Lo d o y rt 'T ✓1 A le ' i- , f { 1/4. _ �ji 3 l T 3 0 , N, R E Property Owner's Mailing Adeffess Nurttf5e Block Number City, State d Phone Number Subdivision Name or CSM Number II. TYPE F 6 IL ING: (check one) ❑ State Owned it Nearest Road pp Public 1 or 2 Family Dwelling - No. of bedrooms town of r R� Orc>Ci 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo �� _ Gam- — 7�J �✓C� 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. prNew 2 E] Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existig System _____ -__ _____________ ______________ n -- - ----- --------- ------- ExistingSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12$j�Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit A 2_ 4 43 ❑ Vault Privy 14 ❑ System -In -Fill r eir i , VI. ABSORPTION M INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 6� 7 _7Z 47,'eet ,,:I_.. Feet Capacit VII. TANK in allons Total # Of Prefab. Site g Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank X 1Z ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Si natu�(N �mp, MP /MPRSW No.: Business Phone Number: 71" 5=3SY--4T67 Plumber's Address (Street, City, State, Zip Cod : IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) pproved ❑ Surcharge Fee) Owner Given Initial (/ Adverse Determination ��-�. y 2 T 3. A zlIl.. X. CONDITIONS O� L 6e— atm— 44 V R E A SONS NOR D�I V� SBD- 6398 (RA 1 /97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks;' distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE f surcharges for number f r la i hi 1983 Wisconsin Act 410 included the creation o su cha ges f (fees) o a o regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. 0 �7__ V -I ! /2/2- - RP&T 13,e R P . *0- Al t"Pc e'-) Gv /. S yo/ <o 2 Wisconsin Department of Industry SOIL AND SITE EVALUATION Page / of Labor and Human Relations Division f Safe and Buildings in accordance with s. ILHR 83.09, Wis. ' o Safety g Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST GP �C O , r � include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 030 • 70•OV-0 APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location '4• #• 4*-A 4 yIiMl IRE 7_ /( Govt. Lot Sf- 1/4 5 J 1 /4,S 31 T ,N,R If E (ore) Property Owner's Mailing Address Lot # Bloc k# Subd. Name or CSM# 27-q 5 om AlH 1hV0N6- PP- 4O -f- 44Z S City State Zip Code Phone Number Nearest Road �(JQSO� `.//. :5 Y10 ( 38 &) 162-3 city Sr. ❑�yo age Lr1 Town ROIiT �iQOU� �' New Construction Use: [residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate / bed, gpd /ft trench, gpd/ft Absorption area required _ bed, ft /7 trench, ft Maximum design loading rate bed, gpd/ff _ ' 9 trench, gpd/ft Recommended infiltration surface elevation(s) SEE P4. • 3 ft (as referred to site plan benchmark) Additional design /site considerations T. FI'LT/Z47 T, 4E1__e e $ ON S �oPF �� f�iP t7 0 K /rI� //� Parent material S,lW 041rlVl¢Z,,- Flood plain elevation, if applicable N ft S = Suitable for system Conventional I �M,ouunnd In- Ground Pressure AT�G a ;teron Fill Holding TanU = Unsuitable for system El U IJ s❑ U IK 5❑ U R S ❑ U S ❑ U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench l o 9 1 3/3 — �- z -Fsb/::� AK w Z f . z 9 L /o .5 If Sh � •w►�/ C • 5 Ground 3 s ' /o 12 �— SL. sh/� 40 l 050 elev. • -� yq, ten. �o s� s — / o. � Depth to limiting factor �in. Remarks: Boring # p •/ L /D A 3/3 • Lt ; . S /J'3 3 /0 Y y S/ c Z f hi-- im -, es S ' , Ground /OR 51 J- O ' s .' elev. Depth to limiting factor �r in. Remarks: 3ST Name (Please Print) Signature Telephone No. Po,w r P/4f ieAT 7a4,A7717/ Address Date CST Number 4& 11 5 Z orry 4 3 5 Ulbf c Private Sewage Con sultan n 655 O'Neil Rd. Hudson, Wis. 54016 o R A L i 13E r kt 'f SOIL DESCRIPTION REPORT 2• . 3 ' PROPERTY OWNER G Page . of PARCEL LD.# 0 30 ' �o 7 Z - 7 O�� ( y e s ) BOrin # Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz, Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 10YR Al? 3 0 Ground �. , J C s G. 0 elev. Depth to — - - -- — - — limiting 1; factor 7 � in. SS: 9l ' Remarks: Boring # i 0- /� /0 R 3 — /f shk fR w f ; • S hfs /W R Y! S/G Cs Ground �• S /Q / S 9 — Q om- - — .7 elev. - S Depth to �/ limiting 5 7 • t 2 factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # D l2 10 0 3/3 n*f zf •y : • 5 S z i 10Y12 3/ S/I(L z f sht .,r, 4. Ground d •s y ©� elev. /6 y -ft Depth to , limiting factor Iin. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: r I � SBDW -8330 (R. 08/95) IMPORTANT NOTE TO OWNERS & INSTALLER: All the finer textured soils (loams,silts, etc.) can & will be easily smeared Or compacted even by a backhoe bucket during trench construction. When this occurs premature failure will result. As per ILHR 83.13 (4), the installer MUST be very careful to properly hand rake the sidewalls & bottoms to re- expose all of the soils natural structure. Minn. even recommends that scarifying devices be mounted on the sides of the bucket. Only in this way can treatment & absorption be enhanced for normal longer system life. C ZN� N � � I r I \ ` f I N V� 3,- 7' � , - � _ s W y v► Q9 . G -- - - - — --�— -1 - -- -� - I � l 1 i I t i : r -- ---+ -- - ; - -- -- Sys- . ��- 172 -- - f I f I I I i 'O -_ - i - - --- - - -- -- �- } ��°- I -� - - - -� l ! : : I ' { : f ST CROIX COUNTY SEPTIC TANK - MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM �✓J�'S� 1 Owner/Buyer - - Mailing Address //� ( Property Address - f —;✓ _ _ i'UV 7– ,, � � (Verification required from Planning Department for new construction) City /State Parcel Identification Number C2 LEGAL DESCRIPTION Property Location /., y., Sec, (, T -30 -R C' W, Town of 5 S J' Subdivision --- -- `'� Lot # Certified Survey Map # . Volume _ , Page # Warranty Deed # ---q 7 G j / G Volume �P S�� . Page # Spec house �1 yes O no Lot lines identifiable �a yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to Dandle wastes. Proper maintenance consists of pumping out the septic tank every three year; or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumberor a licensedpumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Itwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. /ZD l SIG F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro rty described above, by virtue of a warranty deed recorded in Register of Deeds Office. lli 201 SIG APPLICANT DATE * * * * ** An inf rmation that is mis- resented may result in the sari * * * * ** rep y permit being revoked b the Zoning De arlment. � ix r Y s r ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed i �oeunae.�:r r vc WARRANTY GEED r­3 r RE'.EnVEU Ffft RECOROiNG DA "A STATE BAR OF WISCONSIN FORM 2 -1982 4.797:10 - - VOL 936 l� �621 _ REGISitCS OFFICE David J. Waldroff and Julie A. Waldroff, $T. C<CIXCO., W husband and wife as ,joint tenants Reec! for Record -- at FEB 2 5 J11. .. . . 5:00 P. coll"Ys and warrants to .. _..Ernest H. �,Be't and, Lynn J. (� Betker,.husband..and.wife as mar1taj- suryivorship prope.rt -Y . Re9hM►ofDeads .. ... .. .. . ..... .. .. ... ........ .. ... ...... . -. .. ...' - -.. RETU"N To the following described real estate In ... -. -. St ...... C -r State of Wisconsin: Tax Parcel No:.. ........................... SE of SEk of Section 31, Township 30 North, Range 19 West, St. Croix County, Wisconsin. This Deed is given in fulfillment of that certain Land Contract dated August 16 1990, recorded August 17, 1990 in Vol. 878, Page 557, Doc. No. 461476. V / .�... This - is not homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights -of -way of record, if any. Dated this 4th day of February - , 19 92 � .. - (SEAL).! (SEAL) David- J _-.Waldr.off ........ .._._.__.... • ._Julie A.. .Waldroff _ -- -- - --- (SEAL) _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) ._. Ida "r:3d.- J,- __W11dT'Ofi ,-- ----- - - - - -- STATE OF WISCONSIN Julie A. Waldroff $a. - ----- ------------------ ------------ .... ........................ St. Croix ---------- -------------------------- County. authenticated this ........day of -J - .! ?rUary.... 19.92 Personally came before me this - ---th day of February_ 19.92 - the above named --------- •- - - - - -• --------- - -- - -- - - David J. lNaldroft and .. •--- ristin�- ,- Ogland --- Lundeen --- ------ •• - - -- - - - -- Julie A. Waldroff TITLE: MEMBER STATE BAR OF WISCONSIN - ----.---- - ------ -- - -.- (If not . ............. ............. . .. ...... -------------------- authorized by § 706.06, Wis. Stats.) to me known to be the person ,,c ..... __. who executed the forego! instrument p6p acknowledge Li same. THIS INSTRUMENT LUAry "TO NT WAS DRAFTED BY //� NCtdfy Pub Oland Lundeen � -- - Attorney -------------------------------------- - Lillian Ponto vitals o; +�' icons::. -------•-- -------------------- - ---- - - - - -- Notary Public ---- St. Croix_ County, Wig (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(Ii not, state- expiration are not necessary.) date: ---------- January. 3-0 _- ----- - -- _ - ........... 1994. - .) •Nam-y of persona signing in any capacity should be typed or printed below their si6natures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank CO.. Inc. FORAM No. 2 — PJ82 Milwaukee. Wisconsin 'Al •¢o O �P�� /r�E/�Dl� T of /���' / 5 oZD�a � SOIL DESCRIPTION REPORT 5 PROPERTY OWNER Q Page of 'PARCEL I.D. # D •S — �3 ' � O f 7 fl • D�"D 4v Tv STEv Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench I q z 9• /0M 31q ` Sim 12 �s� � �I�e c i� . s ; .4- Ground 7 .S y ie e— Z / S/J� /�I T/ G' •� • S , • Y elev. ft. J • 5 7.57 YA l foT• s'� & /1'1I Al' e5' — • W ; . S Depth to limiting S 7 .5 Y R y C %Owe eel z of S l � factor C ������ 4 S S in. G alx—&A, Remarks: &iV G Boring # S Li �4 Ground 41 f O 19P 121'5 elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # M . y3 . Ground elev. Depth to limiting , r � g -�1� J factor \< in. Remarks: Boring # I� Ground elev. jTb ft. � T X lJr Depth to limiting factor d` in. Remarks: f SBDW -8330 (R. 08/95) 41 ,97 C-7 /f T AEePvES7 ©F oc ►ates c cx �"vi�7 - EJ� � �il9s�/f'll:�.� — `S�/sTFi� -J �i L� tllbcicbt swage consultants 655 at4e%l Rd. '7�j 1 1 - e— Hudson, Wts• 54016 GsV 2 _� z � �7�4 C144 L Ob o j rb 9T ID lzp �,., � '�1 = to (� �. � O o I � c � u►1 c LA km It Qj Vi sconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. 4 / - • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location t r 1/4 i'" 1/4, S 2 1 T :';' , N, R1' "i E (orb N, Property Owner's Mailing AdcVess ! Lot Number Block Number City, State 'Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° Town of III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. [�- New 2. E] Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5 E] Repair of an F -__ - System ________ S�rstem _____________ Tank Only______________ Existing System ________ Ex --- System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 124 ,LSeepage Trench 22 ❑ In- Ground Pressure 42 E] Pit Privy 13 1] Seepage Pit { /r 43 ❑ Vault Privy t . .-.�, 14 ❑ System -In -Fill , ' VI. ABSORPTION W STEM INFORMATIO : 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft_) (Min. /inch) �, = Elevation - e ' Feet VII' TANK Capacity in g allons Total # of Prefab. Site g Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Co Steel glass Plastic App New Exist' structed Tanks Tanks Septic Tank or Holding Tank Lift Pump Tank /Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the responsibility assume undersigned, for installation of the onsite sewage system shown on the attached plans. g P Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: jf Plumber's Address (Street; City, State, Zip Code).' i IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Laesued Issuing A gent Signature (No Stamps) Approved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPR VAk: - 4`�� yy ''ter`` f / w•.C.4C.7 _j J ° v t 1•C� ./�y �. Nk. J [ �Ir�t: �GCLGCYt SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber --O - -- - _y�- - - - -- - - - -- - -- -- ------- - - - - -- �I mss °� •S�'� / 2,( z TiPovT BRaOX R � H ilvV e' .) w /. Sy 2 • Wisconsin Department of Industry SOIL AND SITE EVALUATION Page / of y Labor and Human Relations Division of Safety and Buildings in accordance with S. ILHR 83.09, Wis. County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Cie O(• Y- Include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # a3o /o�'z • 7a•o� APPLICANT INFORMATION - Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property owner �� p �/ Property Location 1/4 5 �1/4,S 3/ T30 a E (or E• f{ . �' Oe I-ymv S ETT -E,Q Govt. Lot 5 .N,R �! Property Owner's Mailing Address Lot # Block# L :N;a::�"� o SMM# S zz •50A4 ME 1e 5 LhV0W & ' PP x • 77 T cit State Zip Co de Phone Number 7/s - Nearest Road tyvQs��J �/• Sy0 /� (38 0) / 7 ❑ city ❑�yQa a OT " Town ovT New Construction Use: &11esidential / Number of bedrooms Addition to existing building ❑ Replacement [ or commercial - Describe: Recommended design loading rate bed, gpd/f1 — ' f trench, gpd/ft Code derived daily flow 9Pd ft2 2 trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ Absorption area required _bed, ft g g SEE' 3 It (as referred to site plan benchmark) Recommended Infiltration surface elevation(s) T ON S/O � '�� �O 4gOK hiS7/Pil3 , Additional design/site considerations :r-0VF 4 Tole.E.y! S s Ay w f-�� � � Flood plain elevation, if applicable � It Parent material fl w -- j Conventional Mound In- Ground Pressure AT -G a Syste n Fill Holding Tank S Suitable for system r,/ El U El U ❑ U0 U ❑ S U U = Unsuitable for system Ltd S El [R S SOIL DESCRIPTION REPORT Structure GPD /ft2 Boring # r rlzon Depth Dominant Color Mottles Texture Consistence Boundary Roots Bed , Trench In, Munsell 11u, Sz. Cont. Color Gr. Sz. Sh. 9 YR 3 �- Z-F �►�R w Z f . y • i 5*1L z h4 Ground 3 G S •7 ' e lev. Depth to r Z limiting u G ; factor � •L in. 7 CP Remarks: Boring # / 1 y /d ,e 3/3 L- /f�Sh :w fie w / • �{ ' . S . 3 �oY� Y — 51 L Z -fS h �+ c --5: SL /f bk 41, O , s Ground -- elev. a Depth to limiting factor ?r In. Remarks: Telephone No. Signature ,ST Name (Please Print) Ro�ER r PMRi 7/ !J Date CST Number Address 2 4l 31.5 c private e Consultants Private Sewag 655 O'Neil Rd. Hudson, Wls• 54018 This test s ite APPROVF0 _ al s� tic system: for a convention p�� a t o�� `a a 2 � 7 rN m Z R � Qo w � m oo ?o -FYAAu. -to o et��� IPE1- T ��T -�(/E� SOIL DESCRIPTION REPORT Page 1 6f 5 PROPERTY OWNER � ee PARCEL 1.13.8 yD �'�s � ' � d �� ' � D • DD-D /TD Tv STED 2 Boring # Hori Depth Dominant Color Mora Structure Mottles Texture Consistence Boundary Roots Geplft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Jrench Cv l o- 9 10M313 L /f h /w�-� z 9• i0 11 3 Sim zfS�6,���e Ground s' S� L Z I s���� elev. �•C / �/• S n. 5 5 � f Yg ?Z J D !, w s D rot liimtingo S V•7 75Y y /O y� 2-- V�S� � — JV •—� factor L in. C �t&NT'�D /f Remarks: &,uG / G Boring # A- 7 7Yle 2 & S SA,t / 7 AV& 7 Z11 le r, " Ground AA* 121'5 �/� D elev. n. N 6V 1 S Depth to limiting factor In. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ; Trench Boring # Ground elev. n. Depth to limiting factor In. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor In. Remarks: SBDW -8330 (R. 08/95) /f AeLPv6 OF , �x ��t- /VS�XA /� — sySreA7 01bticht ow ge Consultants f-aV�' lv�s p5vats eit Rd. /1/��fJS _A> , Yom— Div . N dso . Wts. 54018 VV 710V close 7n o��� 7si X2431 - ��4 �./ 0-1 O �m N -. � a � � I rn, RI 3 71� .- •� w _.. O • w r W N ohs 4 O �;k) i - F�.v►(,L .Gtv� -C A6 T �('ER'f SOIL DESCRIPTION REPORT Page • PARCEL 1.131 0 3 0 - / - 70 ' M ( Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots .> in. Munsell Qu. Sz. Cont. Color Gr. 9z. Sh. Bed . Trench Ground 5 y Q s elev. i� 16 1 r Depth to _ -G - -- - -- - - - - - — limiting factor -- 7 in. . 7 Remarks: Boning # l D• !�/ /0 R 3 L fShK �► fR w f • S QF Ground �• s ye y� - s _ o.� -s — - - . *7 ; elev. - f oft. 7 , / L A Y a2 � _.... Depth to limiting �ffacts / In Remarks: • Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench Boring# p � 1 3 L / hk' nj _` Zf •� ' •S �5 a /oY/t3/ — S/1- 2 fsh, / CS • Y2 Ground a � y O . — — elev. Depth to limiting factor -'-in. Remarks: 7 0 Boring # Ground elev. ft. Depth to limiting factor in. Remarks: ' I � SBDW - 8330 (R. 08/95) IMPORTANT NOTE TO OWNERS & INSTALLER: All the finer textured soils (loams,silts, etc.) can & will be easily smeared Or compacted even by a backhoe bucket during trench construction. When this occurs premature failure will result. As per ILHR 83.13 (4), the installer MUST be very careful to properly hand rake the sidewalls & bottoms to re- expose all of the soils natural structure. Minn. even recommends that scarifying devices be mounted on the sides of the bucket. Only in this way can treatment & absorption be.most enhanced for normal longer system life.