The URL can be used to link to this page

Home My WebLink About014-1063-30-000 (2)I St. Croix County Planning and Zonin F o(__s_�_ ,II Wednesday, Augus[ 03, 2005 at 5:II:34 PM Detail Sanitary Information 91 q _ J663 �34 IOoc) Sec 3ta Page I of I Computer #: 014-106330-000 Sub/Plat: 40 acres Section: 30 Parcel #: 30.31.15.475 Lot: TN/RNG: T31N R15W Municipality: Forest, Town of CSM: 114114: SW 1/4 SW 1/4 Owner: Kuhn, Orville 2614 Highway 64 Emerald, WI 54013 State Pennit: 106079 Issued: 04/19/1988 POWTS Dispersal: Mound Permit: Replacement County Permit: 0 Installed: 04/29/1988 POWTS Detail: NA Bedrooms: 5 WI Fund: yes POWTS Pretreatment: NA Notes Inspector As Built Plumber Other Requirements Additional Notes Money Owed Tom Nelson Yes Myers, Lyle pumped: 5/116195 - This system is first on the $0.00 Signed Off. Yes property - 2004 son built house and installed another mound to NW of this one. Permit is fled with more recent POW -Ts paperwork Owner: Kuhn, Bruce 2614 Highway 64 Emerald, WI 54013 State Permit: 420570 Issued: 11/20/2002 POWTS Dispersal: Mound less than 24" suitable s Permit: New County Permit: 0 Installed: 06/05/2003 POWTS Detail: NA Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Inspector As Built Pam Quinn NA Signed Oft: Yes Maintenance Scheduled Pump Date Pumped 6/5/2006 Plumber Other Requirements Additional Notes Money Owed Myers. Lyle 1/27/03 - Wieser 1000/650 combo tank installed, $0.00 with Zabel filter. Temporary use as holding tank until mound can go in this spring. Owner -signed & notarized temp. holding tank pumping contract agreement to be submitted to zoning office. Pump w/ alarms, etc. to be installed after mound system this spring 2003. This is 2nd house and POWTs on property (farts) 1 st Notification 2nd Notification 3rd Notification DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS P O. BOX 7969 MADISON, W 153707 SW114, SA ,S30,T31N—R15W Town of Forest ITS HTrHWAY 6L INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS ❑CONVENTIONAL ❑ALTERNATIVE ❑ Holding Tank ❑ In -Ground Pressure ❑ Mound SAFETY & BUIC'DINGS DIVISION SUB EAU OF P MBING SIMa Plan 1 D NunKler to .'UI O 9 NAME OF PERMIT HOLDER Orville Kuhn ADORE SS OF PERMIT HOLDER Route 1 Clear Lake WI 54005�� INSPECTION DATE BENCH MARK (q,nH pESCRIBE If OIFF ERE NT FgOM PLAN REF PT. ELEV. CST FEE PT EL V Naml W Plum Ser MPIMPq SW No Caun" Samlary Permrl NumEer le J. Myers 6219 St. Croix 10 079 IZI TANxlNnt n1rJn TANx MANUFACTURER LIOU�IDACItY TANK INLET ELEV TANK OUTLET ELEY WARNING LABEL LOCKING COVER OED PROVIDED YES ❑NO ❑YES NO BEDDING ❑YES NO VENT DIA VENT MAT- /� C HIGH WA ALARM ,,�y(( DYES_ LJtINO__ NUMBER OF FEET FRiM NEAREST ROAD /oa f PROPER LINE WELL n !{ BUILDING IV ENT O FRESH AIR li ET l]ALLVNS Feh LYGLt: (DIFFERENCE BETWEEN /� 0 PUMP ANU CUHIRULS OPLRAIIONAL NUMBER OF FEET FROM YNO''0X^ LI"� QQ1; "' " (� "ET A j�� t PUMP ON AND OFF! YES ❑NO NEAREST—► T SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING. J or excavation Of soil can be rolled Into a wire, construction shall cease until MAIN the sod Is dry enough to continue.) 4 CnNVFNTInNAL SVSTFMI ISTR WIDTH LENGTH NO DPIPE SPACING CDVCA NSLR UTA SPAS LIQUID BED/ TRENCH TRENCHES MATERIAL PIT DEPTH DIMENSIONS Mlf V L DEPTH fILL DEPTH UISTR IPE IRSPIPE DISTR PIPE MATERIAL NO OISTR UMBER OF ROPE Y WELL BUILDING VENT TOFHESH BELOWPIPES ABOVE COVER ELEV INLET ELEV END PIPES FEET FROM LINE AIR INLET NEA REST—> 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 OIL OVER TEXTURE / S� PERMAA�N,{EENT MARKERS OBSERVATION WE LIS LyYES ONO I+YES ONO OE PER OVER TRENCH -BED CENTER DEPTH OVER TRENCHIBED i DEPTH OF TOPSOIL SODDED SEFDEn MUICHEU /F EDGES /e r / J *K OYES I�1N0 Y 3 VES ON O I A VE5 C�NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDT f LENGTH NO OF TRENCHES LATERAL SPACING (TRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS 7� 30 MANIFOLD PUMP ELEV MANIFOLD DISTR PIPE IMANIFOLDMAIERIAL NO OISTR PIPES UISTR Pi DISIHIBUTION PIPE Mp TEHIAL BMAHKINI, ELEVATION AND ELEV CIA �a L ELEV / G DIAIX f/TT// DISTRIB 1 INFORMATION ROLE IZE 1 HOLE SPA('. G DRILLED CORRECTLY COVER MATERIAL VERTIr.AL LIFT CORRESPONDS IO APPROVED PLANS NYES ❑NO NY ERMAN T AR YE ❑NO S OBSERVATION WELLS NUMBER OF PRO'PE�RTY WE`LL-, BUIL�IN�G[ LX0 COMMENTS: 0 L10 YES ❑NO YES ❑NO NEAREFEET STOM O Sketch System on Reverse Side. DILHR SBD 6710(R. 01/82) tain In county file for audit. Zoning Administrator K fi S I4�- � O" 2 sec I d 2CilGGt£i /�u FInJ (� �E-*-jr- ZA c6c [Jr3 Violation Number Form- S T C -101 PRE SANITARY PERMIT ISSUANCE PROCEDURE Location Section Township Municipality Lot No. Blk. No. Subdivision kj �I.S1V14I IT J� N / R �� WI ores Procedure prior to sanitary permit issuance where a septic tank must be replaced during winter weather or other health emergency and soil evaluation or other sys- tem evaluation cannot be conducted. 1. Obtain assurance that thr ,,roperty owner is aware of further requirements for a system evaluatioi,. 2. Obtain assurance that owner is aware that if system is found to be failing, it will be their responsibility to replace it with a code complying system. AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY PERMIT: I, '.J , the undersigned do hereby acknowledge that I am receiving a sanitary permit to t1+ . �TGti without a soil and system evaluation due to inclement weather of health emergency. Furthermore, I acknowledge that a soil and system evaluation will be conducted as weather permits and that if the system is then found to be failing as defined in Section I L H R 83.02 (18), Wisconsin Administrative Code, it will be replaced with one that complies with Chapter I L H R 83 of the Wisconsin Administrative Code. If temporary pumping is to be utilized for maintaining a newly installed septic tank, due to failure of the system, the tank shall be maintained by a licensed pumper in accordance with N R 113, Wisconsin Administrative Code. SIGNED ( /i1N'A�l DATE L�� Z ) - / 2fy A copy of an affidavit in lieu of EH 115 along with the PLB 67 must be submitted to the Plumbing Bureau for purposes of fee reimbursement. Signature of Applicant ate Subscribed and sworn to'before me STATE OF WISCONSIN 1 Thic 18th day of A 19 88. -ve= _ _10001,1111 SANITARY PFAMIT APPI I[_ATInN �, In accord with ILHR 83.05, Wis. Adm. Code COUNTY 2d 1 STATE SANITARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than inches /D� �`� Cy ❑ 8% x 11 in size. Check if revlslon to previous application —See reverse Side for Instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. �1 Sys- O k1 a PROP TYOWNER PROPERTY L0ATION L L'le '110('/4,$ T3(,N,R ISElO PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK f% F CI , STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER III. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned VILLAGE s ❑ Public �1 or 2 Fam. Dwelling—# of bedrooms — PARCELT N MBERO , III. BUILDING USE: (if building type is public, check all that apply) G-00 % 1 ❑ Apt/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 in line A. Check line 8 if applicable) A) 1. ❑ New 2. XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 X Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-FIII VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12.ABSORP.AREA 3. ABSORP. AREA 14.LOADINGRATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQ/UIRED (sq. tt.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./Inch) ELEVATION 6 y/ 1 Ce . —30 Mel/ IM'S9 Feet O2, Feet VIL TANK INFORMATION CAPACITY n ellons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. App. New isti Tanks Tanks strutted Septic Tank or Holding Tank 4 t! Lift Pump Tank/Siphon Chamber, —i Clog QEl Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number: y� 7 Plu er's Address (Street, City, State, Zip Cad e r Z IX. COUNTY/DEPARTMENT USE ONLY Approved Disapproved ❑ Owner Given Initial I Sanitary Permit Fee (Includes Groundwater Fea) //{may ,,,��r Date Issued ef Issuing Agent Signature (No Stam ) /^lsurcharge ?_ 8 ' A ve in • W��• v " X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 the 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. It you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety 8 Buildings Division, 608-266-3815. 7o 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 numbers) of where the system is to be installed. It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. It building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in #1-7. VII. Tank information. Fill in the capacity of every new and/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 8% 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 tanks) or other treatment tanks; building sewers; wells; water mainslwater 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 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6399 (R.11/88) SANITARY PERMIT APPLICATION aiLHR CODUjy_ / ak Id • ` In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. —See reverse side for instructions for completing this application. I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE ❑ YES ® NO PROPERT WNER PRO RTY LOCATION /r ?N It, C tl .Loll , S T J , N, 8 E l W PROPERTY OWNER'S MAILING ADDRESS :OT NUMBER BLOCK NUMBER SUBDIVISION NAME 12 *( CIT STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMAR - Q _ ❑ VILLAGE : �.— III. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b�Replacement c. Replacement of d. ❑ Reconnection of e. ❑ Repair of an 1111 �`�` System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. ❑ Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding C. ❑ Pit Privy d. ❑ Vault Privy e. ;& Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. ❑ Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 15, _ SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ❑Private ❑Joint El Public Feet VI. TANK INFORMATION CAPACITY in aflons Total Gallons #of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. App. New xistin Tanks I Tanks I slructed Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber' Sign re: (No tamps) MP/ PRSW No.: Business Phone Number: r--- Plum is ddress treet. City, te, Zip Cod : Name of Designer:-f- Vill. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST 4 CST's ADDRESS (Street, City, State, Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY Approved Disapproved ❑ Owner Given Initial nitary Permit Fee I Groundwater urcharge Fee ate Issuing Agent Signature (No SlEa) , �/� I n �7 /� �� Adverse Determination ` c �+�+ • X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTIONS Original to County. One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, IitVsiphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; Vill. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 856 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill GrounCn'S included the creation of surcharges (tees) for a number of regulated practices which Wisco can effect groundwater The surcharge took effect on July 1, 1984 All of the water that buried J \ is used in your building is returned to the groundwater through your soil absorption i system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD•6398 (R.03/86) State of Wisconsin Department of Natural Resources Use of thin form is required by the department for any oppilcation filed pursuant to ch. NR 124, Wis. Adm. Code. The department wW not consider your application unless you complete and submit this application form. Instructions for Property Owners: You may apply after you have received an enforcement order and obtained a sanitary permit. Complete Part A of this form, attach evidence of your annual income and send these items to your participating governmental unit at: (Stamp County Address Here) 0Fly c Name of No.* I a 1 -o i f Name of Owner's Spouse Social Security No.* Street or Route _:) (, i Ll_ &� ( y City, State, zip Code D ) a- Telephone Number (include area code) -? Je. S/_ I. 1Ya 1. Legal Description of Property 5 w %.. S f.tJl J h, S -i_. T -3 f N. R _J-'( E I W Lot No. Tax Parcel No. Block No. WISCONSIN FUND PRIVATE SEWAGE SYSTEM GRANTS OWNER'S APPLICATION Form 8700-127 Rev. 4.88 TO BE COMPLETED BY DNR Application Number Date Received State Share Pending Statue -- 71 Name(s) of Additional Owner(s) and Their Spouse(s) No.* 'Note: Disclosure of your social security number is voluntary. Refusal to disclose it will not affect your application. If disclosed, it may be used to verity your income. u city ❑ village of��' 19 Town Subdivision Name Register of Deeds Document No, 2. This application is for (complete both, if applicable): 19 Principal Residence Do you occupy this residence at least 51e% of the year? ❑ Smell Commercial Establishment — Brief Description 19 Yes ❑ No S. Are you, or any of the persons listed above, a licensed plumber or contractor engaged in the ❑ Yes CA No business of installing private sewage systems? 4. Uniform Sanitary Permit No. Date Issued 9 g 19 16 g Q 7 9 I Me D Yr b. Evidence of Income Attach a copy of your Wisconsin income tax return for the year prior to the enforcement order. If you are married and filed on separate forms, you must also include your spouse's Wisconsin income tax return for the same year. You must include evidence of income for each owner tend for each owner's spouse) listed above. Evidence of income will be kept on file at the governmental unit and is subject to verification by the Department of Natural Resources and by the Wisconsin Department of Revenue. If you or any owner listed above did not file a Wisconsin income tax return or were a part -year resident in the year prior to the enforcement order: check this box ❑ and contact your governmental unit for further instructions. 6. Property Owner's Certification I certify that, to the best of my knowledge and belief, the information I have provided on this form and all attachments is true and correct. Signature of Owner -Occupant ,/ p Date Signed Si�najtturels) of Co-O ere) %f Date Signed (or Business, �s_ „�%�_ � . K...l..-_. 1 _Jt�b�.t - 3 0 - 1 44 q 1 PART B. TO BE COMPLETED BY GOVERNMENTAL UNIT Eligibility Checklist: 1. Private sewage system failure caused by discharge of sewage to: (Check all that apply) ❑ Surface wator or groundwater Category 1�❑ A zone of saturation ,,r❑r� A drointile or a zone of bedrock Category 2 !31 The surface of the ground Category 3 ❑ Backup of sewage into the structure served Note: Owners of systems which fall in Category 3 only are not eligible. 2. Has a written enforcement order been issued? Yea ❑ No Date of Order o 31 ) q 18Y Mo. Day Yr, �n 3. Was this principal residence or small commercial establishment constructed prior to and occupied by �[]- Yea ❑ No July 1, 1978? 4. Is a public sewer available to this property? ❑ Yes No 5. Has a previous grant been awarded for this property under this program? - ❑ Yee f® No 6. Does the owner's annual income exceed the program income limitation? . ❑ yes lcv No Please indicate whether the income limit In your county is ❑ $32,000 OR ❑ 125% of County median %cam Evidence of income an file: ® Wisconsin income tax form, year 19 7 ❑ Affidavit for low income residents ❑ Affidavit for new residents ❑ Affidavit of estimated Income reduction in year ❑ Tax exempt nonprofit A Note: The total income of all owners and their spouses must be considered. Keep evidence of income on file at the county or governmental mrit. Do not send it to the DNR. 7. Verification of Ownership Has the ownership of this property been verified by checking the deed or other documents on file yea �: No at the county? Replacement or Rehabilitation Information: (attach a copy of DILHR form PLB-67 and drawing) 8. Type of System El Conventional � Mound ❑ Other (please attach plans) ❑� In•Ground Pressure ❑ Holding Tank 9. Number of bedrooms c OR design flow in gallone per day y 150 = 10. Soil Test ® Yes ❑ No 11. Replacement or additional septic tank, minimum capacity required y gallons, r 12. Lift pump and chamber ❑ Yes No 13. Percolation Rate (if conventional or IGP) OR Soil Limiting Factor (if Mound) ❑ 0 to less than 10 yo High Groundwater ❑ 10 to lees than 30 ❑ High Bedrock ❑ 30 to less than 45 ❑ Slowly Permeable Soil ❑ 46 to 60 14. State share requested i ri 1-7 Q 15. Eligible -- ❑ Ineligible, Reason: 16. Governmental Unit Representative Certification I certify that I have reviewed and verified all Information provided on this form and attachments and that it Is true and correct to the beet of my knowledge and belief. I -I 1 State of Wisconsin Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION PRIVATE SEWAGE PLAN APPROVAL Office of Division Codes and Application 201 East Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 LYLE'S PI._G, 6 REPAIR Owner RT. 2, BOX 47A BOYCEVIL_LE, WI 54725 RE: Plan Number: S88-04810 Gallons Per Day: 750 Project Name: KUHN ORVILLE Town of FORRE:ST Fees Received (Priority Review): 160.00 ORVILLE KUHN RT. .1 EMERALD, WI 54012 Date Approved: December 9, 1988 Date Received: December 9, 1988 Location: SW,SW,30,31,15W County: STCROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT MOUND — NEW MOUND NOTE: This approval does not include plans for the general plumbing systems or sewer piping to the septic/holding tank that is required for this project. Those plans must be submitted and -approved. SBO-6423 (R. 08i88) State of Wisconsin LYL-E'S PLG. 6 REPAIR Page 2 Department of Industry. Labor and Human Relations SAFETY & BUILDINGS DIVISION Inquiries concerning this approval may be made by calling (608) 266--3937. Sincerely, MES QUINLAN Section of Private Sewage Division of Safety and Buildings PPP012/0009n/ 4 cc: ORVILLE KUHN __Private Sewage Consultant _. County ___UW-SSWMP __-Plumbing Consultant Owner Plumber Environmental Health SBD-6423 (R. 08/B8) Eilt)�.i�'C: �•iIZJiGG c /'�J /,� � W y�;.J w Y� ,r. ,. , ��.. �,,,• '.r". .�,". -SKr : �L!•� � 5��••�r�O.J ..r. ,. ,,•. Nr7 '- Dt vnis 14-7 P - 1 � n.,--T (//�(�/��,� NI I ' I . t e I' ` `ski•sly+ 'y�y3� 1 �U . Geis n S `t Yd�, . � ,J 1�"'[1.+•� ¢�� t" -'- •� 17.6/Y. 7 - It�i'•.'.-A % ' >j fJ: j > .. _! I!1 x•.a L, y. :.»I1 1 .IVILI��i� I :1x1'y � -I:a .. dlbaMM v � d""rs � Y'�I.♦`', h 5\\�Iv I� �J IS[/K. s� ��/ \ 'J�, /'� 3/ ' }' ' ? 7IR 4' 3?rl` ~• tiG •Ylt?a 1'•Y7i T '.YT1 . T�,�. `�•"I( �i4., a � i�� "'�, Y ilt•, f l'Y• [ •! , �: fia' I !, OrJt�_CO/4�i/ r` °,,`�Li; , +fit ,tu.1st Y.� Y .. •xu [^a 1 1 r /� I a thi n,.rystCm3Ov.n saes SC:[ l,+ x �, ` }.� ." "1' •"''l nIJi+IMnQ-SJr'T Hi rcnk Vial i5 ,.'e41}i°er1, .hr Fr7'. G:'r;cCJ. .fl'tx'i lea�a .•..:- must he ;UbMiliel irp.�p�rrned,,n acrbrdaacu /,-wnh KVH Straw, Marsh Hay, Or Synthetic Covering, Medium Sand Topsoil _J E 3 % Slope Bed Of 20— 2 %2 Aggregate Page — Of _ S 88- 04810 Distribution Pipe G Force Main \ Plowed Layer D 1.59 Ft. Cross Section Of A Mound System Using E kS 5 Ft. A Bed For The Absorption Area F 75 Ft. G I.D Ft. A Ft. H 1,5 Ft. Signed: �� B Ft License Numbe : elo, 2 i K Z, Ft. Date: leg L __0Lj_ Ft. r, j 10 Ft.� Alternate Position I 12. Ft. of Force Main W 31 Ft. L FA F Observation Pipe--,,, — — o I.---------------------- -------------------- - Force: Win Distribution Bed Of 2 —2'' Pipe Aggregate. I ={" Observation q4pel (�- Permanent Morker51 IiOU i Plan View Of Mound Using A Bed For The Absorption Area Perforated Pipe Detoll Page _ Of S88-04810 s Located On Bottom, 'e Equolly spaced rnote Position Of Main Ft. _ Inches Y G_ Inches Hole Diameters Inch Signed: �— Lateral ► IL Inches) License Number: f1�� / /� Manifold Inches Date: r ' Force Main " 3 Inches # of holes/pipe -, Invert Elevation of Laterals /01.35 Ft. bLL �' I U /'��•-� �. ----_ PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS PAGE 0 F VEU7 CAP S 8 8 _ 04 81 1 4*C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUAICTIOAI BOX MANHOLE COVER C<=(!-i.-.+�-•1 25� FROM DOOR, !i WINDOW OR FRESH 12'MIU. lrt ,L i%' AIR INTAKE GRADE i I 4" MtIJ. IB" MIU. COQCUIT -- _____—___ IKLET PROVIDE APPROVED JOIPJ'r A /- - I III APPROVED IOIVTS W/C.I. PIPE I III WIC.I. PIPE EXTENDING 3' - I (I ALARM EXTENDING 3' ONTO SOLID SOIL I II ONTO SOLID SOIL I I c Oc, A...:-:: 33 CLCV. J FL OFF D .,. CONCRETE 6�-OCK RISER EXIT PERMITTED OAJL4 IF TANK MANUFLCTLRCR HAS SUCH APPROVAL �j• 1/ SEPTIC F SPECIFICATIOUS DOSE 1 4 TAUKS MANUFACTURER: �I�lii�l ��-�� QUIMBER OF DOSES: PER DAU TANK SIZE: 1000 -GALLONS DOSE VOLUME 187.5 ALARM MANUFACTURER;--1+1 �"y INCLUDING BACKILOW: 'S GALLONS MODEL DUMBER: \\N � CAPACITIES:,/ = Z3 INCHES OR 5'dGALLONS ! SWITCH TtlPE: ry^�, - B= 2' INCHES OR_...L—'2GALLOUS PUMP MANUFACTURER: INCHES OR n 4 '1'� � �9_ GALLONS MODEL NUMBER: -7 J D= INCHES O GALLONS JJ tt T;X . SWITCH T'dPE: F74 NOTE: 7-4MP AND ALARM ARE TO 9E MINIMUM DISCHARGE RATE g9'10 GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEU PUMP OFF.AND DISTRIBUTION PIPE.. 910 FEET + MINIMUM NETWORK SUPPLY PRESSURE , " , , . .. . . . . 2.5 FEET + --�- FEET OF FORCE MAIN X ---'.�5 FYooft.FKICTIOU FACYOR.._- FEET TOTAL DyNAMIL HEAD = ( l/ FEET t it INTERNAL DIMENSIONS OF TANK: LEAIGTH_? ;WIDTH �II 1 ;LIQUID DEPTH SIGNED: LICEMSE NUMBER: � ��" DATE:�� r 0 941 32 30 28 26 24 22 20 18 is 14 12 10 s 6 4 2 0 ;AL LITERS 0 80 160 240 320 400 T ERING PACITY PER MINUTE E WATERING 193 165 lay U6 119 'gal. WS. eat.! E11S. Gal. Urs do.t. Url, Gm(�Urs 61. 231 61 231 65 322 61 231 61, 231 65 722 60,, 227 '60! 227 - .65' 772 59 227 60: 227 As 722 5T : 216 59 227 ;,v7 65! 722 6s : 206 66 220 90. 340 'r 65'� 722 46 172 '65 200 75: 203 ^69: 337 . 63 314 73 1y5 sr, 191 56 219 73' 276 27 292 is $7 ,43( 161 36 176 -57. 216 ..67 253 JO' 114 10, 36 37. 140 ."SL^ 216 ;36=: 138 r , so 66 ar 13 as 110 S 88 - 04810 �• c��2G �Z ��, Wisco nsin Department of Industry, QNSITE SEWAGE SYSTEMS Labor and Human Relations Safety and Buildings Division PLAN APPROVAL APPLICATION Office of Division Codes and Application Onsite Sewage Section 201 E. Washington Ave., Rm. 141 P.O. Box 7969, Madison, WI S3707 (606)265.3615 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The reverse side of this form describes most of the required plan information. Further requirements may be contained in the Wisconsin Plumbing Code, which can be purchased from the Department of Administration, Document Sales and Distribution, 202 South Thornton Ave., P.O. Box 7840, Madison, W153707,Telephone (608)266-3358. 1. PROJECT INFORMATION (Type or print clearly) Plan Number Previously Assi ned S S -- C) 3 Name of Submitting Party (plans returned to same) Project Name Street Address, P.O. Box / or Rural Route Project Address or Legal Description City or Village State Zip Code City ❑ Village ❑ of Town ❑ County Telephone No. (include area code) Designer - - Name of Owner Telephone No. (include area code) Telephone No. (include area code) Street Address, P.O. Box 0 or Rural Route Street Address, P.O. Box N or Rural Route City or Village State Zip Code City or Village State Zip Code 2. APPLICATION FOR: ❑ Experimental ❑ New Construction ❑ Large System ❑ Replacement ❑ At -Grade ❑ Revision ❑ Pressurized System ❑ Mound System ❑ Conventional Gravity System ❑ System in Fill ❑ System in Flood Plain (attach SBO.6698) ❑ Holding Tank ❑ Groundwater Monitoring ❑ Petition For Variance ❑ Other Alternatives 3. FEE COMPUTATIONS (include existing tanks) FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO SAFETY 6 BUILDINGS DIVISION. a. 750- 1,500 gallon septic tank S 50.00 b. 1501- 2.500 gallon septic tank S 60.00 C. 2,501- 5,000 gallon septic tank S 80.00' d. 5,001 - 9,000 gallon septic tank $100.00 e. 9,001- 15,000 gallon septic tank $150.00 f. Over 15,0150 gallon septic tank $250.00 g. 500- 1,000 gallon dose chamber S 30.00 h. 1,001- . 2.000 gallon dose chamber S 50.00 i. 2,001- 4,000 gallon dose chamber S 70.00 j. 4,001- 8,000 gallon dose chamber S 90.00 k. 8,001 - 12,000 gallon dose chamber $110.00 I. Over 12,000 gallon dose chamber $150.00 M. A. o. 500- 5,000 gallon holding tank 5.001. 10.000 gallon holding tank Over 10,000 gallon holding tank S 30.00 S 55.00 $100.00 p. Revisions $ 20.00 q. Groundwater Monitoring - Per Site $ 32.00 (other than a proposed subdivision) r. Petition For Variance: Setback $ 25.00 Site Evaluation $ 50.00 Subtotal: s. Priority Plan Review: Enter same amount as Subtotal Total Fee: SBD-6748 (R.04/88) NOTE:Fees are pursuant to Wis. Adm. Code, Chapter Ind. 69, and OVER are subject to change annually. 1A ,_Depa inent of IndusState of Wisconsin AUSU 5 t 15" 1988 L�+LYI.E'S PLUMBING & REPATR LYLE J MYEOS RT 2 BOX 47A BOYCEVULF, W1 54725 RE,. Plan Number.S89 Project: KUHN, ORVTLIX Location: 6W,SW,30,31,1514 FORFST This letter is to acknowledge race to the Office of Division Codes an W4 cannot however, proceqs your su 1. Soil. boring and percolation too Tester. 7ncludo elevatioh, sot properly defined bonchmark and A detailed plor- pl.inj' 4 Additional information requited a Section TLHR 83.00 (2) (a) Labor and Hurn"'a - n RIlation's SAFETY & BUILDINGS f f Olvision Codes WW Washio(iton Avenue :J 7960 itur Wisi.ansin 53707 ORV:11-4 KUHN RT I FMFRALDf.W1. 54011 A-, • Fee Received: Date 11*40ved: 0 of thee' 1)04ion which you submit Application,! .Section of Private 8 littal un tWuro rer.aiye: data on'ta 115 form signed by a Coil boring qM percolation data. Alp )cation{ of existing system($), b y ropirl4"' 9 isned ao pir Please retain one rqm 'f_this lot er for reference and, -1return the *T the_yktterials rNit'03Le—d- : Your Petition will he processed wi hin 30 workil04, ,ayr by the Section, fol-lowing receipt of thi requesta(0itomj. Petitions or plans suhmitted to thWofftca whi '�Cqui re aiwt.itonal,, M 'P;� will be held 90 working days. for riltaipt of the.4 formation.If, cift4it d, response to this letter- brA s not be be recto on received, ja .,r plans will N&Ur submitta If you find it necessary to,�he ontac us req*H inS' I PI (608) 266-3937 and refer to pl numbe' ar, *.V-..Wn above. ri A E. days it us oil K 06 SBD-6423 (R.10W) Uf Wisconsin ` 9partment ofIndustry, Labor and Human Relatigns r� r A. SAFETYtiBUILDINGS OIVIS 1 ; ,. ! ,f '�` I I �Il '1if11ll�i �tn'YIfN ;� ,.".• ` ' � • f I it Pe'Y'IQ'�, PLUM1ST,NC & REPAIR AUgU3 Si e0 )Cq S v /k K4 r ihi 6 $inee �� 1 ,yn,j, h-'i,/�.(y`. ')Y • � . AME8 Q11 N", h v SOcticn Private•tawaga 1"Division 'f Sat'etij.,and Sur Id A 1 A PPhO12/ 1n/ 1 r COMP ;. "t ti i ft. s.�•• �.r�a's• EL t: �y t[ t _ my z Plumbi:a `Consultant- I.ncal PI �P�ymber _ �Env iron rntaI Ilgalt ` raeiIttias Need Anal is Onion SUM' SSWMO ' } Dept a gricµltur,e �Privat'e Sal+rAge Con3 i *`' 1 • } Al TU I ; k. y w 4 y p � i� r I� •. rM 4 , •y :. iM { j State of Wisconsin Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION I'l �lnhfj' 2.0, 1911R A Wid Apjj I i OJ Ua!I It,, i. i 0) fl, A "' ' I , ; I : M(ad-j.!;on, Lj 'S P1,11i"PIM; & IN J MY[ I!!" Q! 7 PDX 'i7'A I"OWTVII 1.1 1,411 Y1 7 1114 .4!ill n 1.11 5 10 12 Rr: Plan Number 588-03335 I'j'-1 04 1 P&AIM' : I"01 U I I I I Rf'kaI Df ':'Cl X 910 C10 I iwol iow !1M, f)/') I /Ito !i i-i I I fit Il, ro,: 1: It J I hill i t I Cd 14" 1 tif Off i f, fli vi ills, Apr. 1: i 1 f n;: (..:.;Al i r1c;1 I i r- i (-.I •,III lif. 11jack! t'; I wj (."Of" t Q1, I 1 111 1't I I I 11 P FOR RE-1-1 ! I Pn-1 III, ...... . ...... ....... —:-- . , . - -- I hi If I i or flillf'i. ho pN '--i; idol) if V� ... r,,.. ,,Ill-j 1: i ;. (I ri , I y , y I nubs r li 110 111 A I of 1141 ..I PI 10 1. el1i..41y j 11 V At C I s , Ij SOO-6423 11111,101871 ST. CROIX COUNTY WISCONSIN ZONING OFFICE 796-2239 (HAMMOND) 425-8383 (RIVER FALLS) HAMMOND, WI 54015 May 27, 1988 Division of Safety and Buildings Bureau of Plumbing P. O. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Orville Kuhn property -located in the SW 1/4 of the SW 1/4 of Section 30, T31N-R15W, Town of Forest, revealed suitable soils at a depth of 17 inches, below which high groundwater was noted. This site should be suitable for a mound system. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, `1- h o h-1 &,3 C. Nk Thomas C. Nelson Zoning Administrator rc .--�eETITION FOR VARIANCE WISCONSIN DEPARTMENT OF OF A RULE IN THE INDUSTRY, LABOR AND HUMAN RELATIONS WISCONSIN ADMINISTRATIVE CODE DIVISION OF SAFETY & BUILDINGS P.O. BOX 7969, MADISON, WI 53707 OFFICE USE ONLY Petition No. E— umber Name of Owner Building Occupancy or Use Agent, Architect or Engineering Firm Company s Tenant Name, if any Street & No. Street & No. Building Location, Street & No. City State & Zip City State & Zip City County Phone Phone Plan Numberls) IF KNOWN Name of Contact Person 1. Rule of the Wisconsin Adminstrative code cannot be entirely satisfied because: 2. In lieu of complying exactly with the rule, the following alternative is proposed as a means of providing an equivalent degree of safety: 3. Supporting arguments are: ------------------------------------------------------------------ VERIFICATION BY OWNER • PETITION IS VALID ONLY IF NOTARIZED For Fee Information See ILHR 69.15 or Contact The Department at (608)-267.7843 NOTE: Petitioner must be building owner. Tenants, agents, designers, contractors, attorneys, etc. may not sign petition unless a Power of Attorney is submitted with the Petition. being duly sworn, I state as petitioner; that I have read (NAME of PETITIONER Please type/print) the foregoing petition, that I believe it to be true and I have significant ownership rights in the subject building. Signature of Owner Subscribed and sworn to me this date: Notary Public My commission expires: County, Wisconsin. OFFICE USE ONLY Date Received Amount Paid Receipt No. Department Action Office of The Secretary Date SB$ (R. 12/84)