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HomeMy WebLinkAbout040-1045-30-000 • AS BUILT SANITARY SYSTEM REPORT ,. TERzf Z L /il/1?t , TOWNSHIP l SEC. a IN. T N, R j. ADDRESS , ST. CROIX COUNTY, WISCON 3 DIVISION , LOT LOT SIZE PLAN VIEW -Distances b dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -� - -,- I - _ !7 _ _fR A I i Indica Totth Azro r SOLE: , I 'TIC TANK(S) MFGR. %, _ CONCRETE STEEL NO. of rings on cover Depth / DRY WELL :" '4CHES NO.-of - width length area no. of lines widt length i / area depth to top of pip RATE AREA REQUIRED AREA AS BUILT riaimer: The inspection of this system by St. Croix County does not imply complete .'k: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 ,tern operation. However, if failure is noted the County will make every effort to 'ormine cause of failure. '�;IASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST `INSPECTOR , G DATED ,,1 —� ? PLUNID3ER ON JOB cam LICENSE NUMBER ��i�i REPORT OF INSPr t _ _ SEWAGE �, F - .CTI011 I.�DIJIDUAL .,EWAGE DISPOS11L SYS E1-1 Sanitary Pei`r�i.V r State Septic ,17 � �/ fw ��'` 1E � TOWNSHIP t. OlX County Sr -PTIC TA' ?S� ' 'xze O j gallons . lumber of Compartments � - Distance From: Well �`� £t, 12% or greater slope it. Building `_ / ft. Wetlands f tiighwater L " ft. DISPOSAL SYSTL: _Tile Field or Seepage Pit(s) Distance From: tTell. 5" ft, 12% or greater slope - - ft Building; _e ft, Wetlands f:, FIELD Rig;hwater — ft. Total length of lines t ;Z C) ft. ! lumber of lines 0 Length of each line 4 0 ft, Distance between lines ft. Width of the trench L . - ft. Total absorption area ` sq , ft, Dept;; 9f rock below tile / in. Depth of rock over tile 2.. in. Cover ---- ovex.rock,, Depth of tile below grade in. Slope of trench '2— in per 101 ft, Depth to Bedrock — ft, Depth to ground water PITS r Number of pits s' de td ameter ft. Depth below inlet ft. Gravel a A ) OU it es no, Total absorption area �sq. ft Square feet of sepp"ag;e trench bottom area required } :square feet of s a epa.e of re required cy • Inspected h' Title':. - • Approved ,.: Date �S___ �______ 197,,,9 PLB67 State and County State Permit Permit Application Count Permit # PP Y —�— for Private Domestic Sewage Systems County *DENOTES STATE *Al REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: AL L, N o g r A0 7 SS/�Y �v, M/4.5 . / M'r AIA/ . Ss 3v B. LOCATION: I ;yV % %, Section /D , TZ_6 N, R LC - W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township T— gby C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms A 4 77 No. of Persons Z� D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES�LNO # of Bathrooms J& Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) 6 Total Absorb Area Z jjj1W ft. New Addition Replacement *Fill System &LO Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _ Seepage Bed: Length Width Depth Tile Depth 3 No. of Lines 3 �r Seepage Pit: Inside diameter Liquid Dept Tile Size Percent slope of land /02P -- /27P Distance from critical slope 3Z' I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester, NAME - JAMes E C.S.T. # S,j -���° and other information obtained from /� d&l '` (owner /builder). Plumber's Signature MP /MPRSW# /�3 Phone * 7 1 r_ 3 & _ 3 4 3' Plumber's Address ®. _ Syy1 4 PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). V ,p ov i a 'u # n h n A4 3 r `r is r WT E �.z 5. il . �. - r ,r'e.::. ,� 6i�?e � € k "f+` 3.��'�'�� k��'¢s'�r•r`" t"' ro� y +•�'�� s � y ' 'yt','.`'� � �f p F �� a yy r v "t* ' Ky '� n �� ,r"a"•` 7, t Et � e# � n Y 3� ,ta • _ Y 3 4 � RF Sr 'f ya "taaF6� 1Warr z AAW S a { "� ENO l k RM F p ,u 7 Gw +3 a s` " r a t� .� � ,�aY� "`M' � m e f . r ` Y '�,•: , a ?` `fit - } t tt F 6 �'Fcr 3F e' , _ s iFHy F& < ! w y y ��S a t,....:. OWN ST. CROIX COUNTY ZONING DEPARTMENT, AS BUILT SANITARY REPORT i Owner - Property Address 3 sr fQ�� City /State i'ar �v OP Legal Description: Lot y uPf Block INA- Subdivision/CSM # yj tia t/. KW t /., Sec. t O • T o;8 - R l9W, Town of - Tf LA PIN # 040-10 If�• Y•1 SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION Tank manufacturer W ► P Ste_ Size ST/PC( 5 ks S etback from: House --� I Well "75 4/L Z Pump manufacturer - _ oael Alarm location (HOLDING TANKS ONLY) Setbacks: Service road A ,* Vent to fresh air intake N A Water Line ,Qfi Meter location _rUA Alarm location A)I+ SOIL ABSORPTION SYSTEM +1 rj 4c; Type of system: y Width Length Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark �' �' oil P U G 0 C Elevation /O—D , 0 Description of alternate benchmark W r < D Elevation /D 6 Building Sewer X60 • ST/HT Inlet �q' ST Outlet Q PC Inlet PC Bottom --- Header/Manifold �� • , Top of ST/PC Manhole Cover ��• Distributio Line () () Bottom of stem ( ) O ( ) Final ade () () ( ) Date of installation / / / / ,2 /q 3ermit number &)4UV4 State plan number x) Plumber's signature License number 6 Date M-12G Inspector D Complete plot plan Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division T . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary24r664 Personal i nnf ff ormation you provice maybe used for secondary purposes [Privacy w, s.15.04 (1)(m)]. � [1[1n1 @TD & SANDRA ,�Cjty [] Village Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: ParcelljrjS.21 -30 -000 TANK INFORMATION ELEVATION DATA A9 TYPE MANUFACTURER CAPACITY STATION,#/ BS HI FS ELEV. 7 e 1A1 �� e� chm _ Q W _. 4WAW a Dosing N 1 � q. Aeration Id S °er )ct g 37o , AT . Holding /gylnll et 9 g ", 11 TANK SETBACK INFORMATION t Outlet, 1 4 7 TANK TO P/ L WELL BLDG. Air U6 to r i54 Intake ROAD Dt Inlet Se ? NA Dt Bottom Dosing NA Header / Man. Aer on A Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH I Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM DIM SETBACK SYSTEM TO P/ L BLDG I WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER mod Numb System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only x Mulched Depth Over Depth Over xx Depth Of xx Seeded / Sodded x Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 10.28.19.150C,SW,NW 633 COULEE TRAIL - Torp o Plan revision required? ❑ Yes x No �o ( -/ Use other side for additional information. - / [_jl(S[7b I SBD -6710 (R.3/97) Date Inspector's Qnature C ert. So' Petit 7 1$' �4wwn lA x�►J - ` �- tou .o' o�u g , 3lV brq. Pv c Ol Pe ,(j NE goo' '• _ Wp�►t 9 OJ b -- -� n.t�cl�t1NG S�n 'rM.ht � 8E fjs�pa�l�p 3 '�O `o e •, flL`R�'R1vt1T� 1 .3 ¢L4 �� s n Safety and Buildings Division A sbons i n SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. Cod • See reverse side for instructions for completing this application state sanitary Permit Nu ber So 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 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property O e Name Property Location /4 ., j /4, S T N, R (Oro Property Owner Mailing Ad ress Lot Number Block Number City, 5 a )e Zip Code Phone u ber Subdivision Name or CSM Number TY PE OF BUILDING: (check one) ❑ State Owned ❑ ity ge T N ❑ Villaearest Road Public or 2 Family Dwelling - No. of bedrooms s wn OF Couc �c l L. III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax 1 [] Apartment /Condo ©_U z ^' 3 a 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. ❑ Replacement 3. jX Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System _____________ Tank Only______________ Existing System ________ Existin�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 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 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 Feet Feet VII. TANK Capacit gall Total # of Prefab. Site g Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks Tanks Septic Tank or Holding Tank �/(/��f ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's me: (Print) Plumber's S ture: (No MP /MRRM No.: Business Phone Number: 06 tom- 1*&Ao Plu berit Address (Street City, State Zi� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) VApp roved Surcharge Fee) ❑Owner Given Initial Adverse Determination ^ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.1 DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber Labur a nD ep nRel toffI n dusb , SOIL AND SITE EVALUATION REPORT Page N of 3 Div n of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY complete site an on �� Attach com p plan paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. O q O- 1 y S- 30 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION D Q \ S f�hl� \� �jZ,t, .f -G, T Sw 1/4 1 1/4,S 1D T Zcd AR l q E (a PROPERTY OWNER'S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM # 33 CQ" Lkre 'TvAl L — — CITY, ` STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®TOWN NEAREST ROAD S 4,016 (-) IS) 38 6 - 59 0-7 1 CDV 0ZL- [ ] New Constr Use [X] Residential/ Number of bedrooms S Additkn to existing building Replacement [ ] Public or commercial describe Code derived daily flow -1 S o gpd Recommended design loading rate - bed, gpd/ft •2 trench, gpo1ft Absorption area required \O bed, trench, ft Mabmum design loading rate bed, gpd/ft2 -11 trench, gpolft Recommended infiltration surface elevations) 0 LZ- S it (as referred to site p Ian benchmark) nom Additional design / site considerations z ` e-tt� 3 tov" w/ L�e.lt e. Ff#�rrs3 �frS (sei� IvuT-� ahj Parent material Flood plain elevation, if applicable V)• it S = Suitable for system CONVBJTIONAL MOUND IN GROUND PRESSURE I AT - GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0 S 11 U ®S ❑ U ® S ❑ U M S 11 U ❑ S E U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounfty Roots GPD /ft in, Munsell Qu. Sz, Con, Color Gr. Sz. Sh. Bed rends ] o -z% 1�`�R zC2 — L Zmsbk �� GS s b Z z.a - 31L si I Zsb�r wiTi, Ground 3 bb - ` L O`7 tz Y b — S 19- G► - rnl I •� . $ elev. t� `I it Depth to limiting factor Remarks: Boring # 0 -$ �r3-t►z a l2 Gh L Z s bk N �►� c S — . S Z Z �' - �y. 10-ttz V secs 1 " 1 �sb �^'►v �S 1`4 s Ground 3 y Sy Ib`�tZV/ Sds�( i-�sbl, ��►- CS .5 . elev. 00.0 3 �o ►�, s eu z '✓ RFC I L 4. Depth to c) 1 .f 6ml6ng - fact - ` S o T � r i CR (�.... Remarks: ING6�kjC T Name.— Please Print Phone: - -- - -� Arthur L. We erer 715 -425- eg Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022 ' Signature: Date: CST Number: M00576 �. PLOT PLAN Page N of SCALE 1 "= 14O ' Prhn7 - Ls' Fp4wI AVYQoWYIPf'C� 11��'17� . /)(� �- - LL lOU .O Ors q Y �\} � 3 f p �•q _ PU 0- 1?l P@ pQ-oPU 9ptj 1� ego' � v�rs _ e��'ro � . 4 � - - � o S3� -el .�Oo.9 On► 'tiiP o� 'Z t�clS11NG SE1�Ti 'M'�. 3`J � 0 ►-t 1ti+ . ��l Z-S 6l� lonl `M'NYi> AL`tPhiRTE 1 `'1.Op O x �i 1 s ti _ z 7R rct}Lss, c-t\ 3',Y- goo' [.�uC w L714 l6 uNt"..of _T Cr Z. s 0 7; -z -� ( 715 ) 42. 5 -ni 65 M 00576 CST Signature Date Signed Telephone No. CST # ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer 4 Gt l r`GI_ ,�r Lt yVl ✓V1 e 1 Mailing Address �( p� ] I Property Address i\ t 1 _ \ �p r l (Verification required from Planning Department for new construction) City /State N Lk JS (5y-\ Parcel Identification Number (I� Q o Q0 LEGAL DESCRIPTION Property Location �W '/4, ' /4, Sec, b T -R,_L? W, Town of TkQ Subdivision Lot # Certified Survey Map # J Volume , Page # Warranty Deed # f 3 4 9 Volume — Page # Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years 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, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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. I/we, 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 o e three year exp' tion date. p� S ATURE OF APPLI ANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** 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 THIS SPAC[ R[S[RF[O ROR I,[COROINO DATA DOCtJMENT NO. W ARRANTY DEED • J STATE BAR OF � SIN,F 2 — + 9 j411�9 - �;. 13 PA �C - REGISTERS OFRCE Allen C. Lindh, a single person -- .......... .. ........... .. ST. CROM CO., WI& _.. .... .. R�t'd. for Re"d this 30 ............ . April - of__A.D. 19_ .. -- .. .............. ... .. _. ... _ 8:30 A M. David G. BrLUrrnel and Sandra b con - veys and warrants to .- �' .Brvrrir>el,.hu�'�and -and. wife as . survivorship - marital- •- - - - - -- . -- ---------_-- -- - - - -- ------- ------------------------ - • . .......... - • . . . .. . .. ............. . . .. .. � HE FIRST NATIONAL BANK - - - -,,,- , -•- R[TURN TO T HE .. ... ... •i ^� -- -- . _ ._.... - - -- .. - -- - - -- -- Al l S , 54022 _ 811 3_ r _ WISCONSM the following described real estate in ..... St... Croix------ -- ••------ -..... County, State of Wisconsin: Tax Parcel No- --------------------•---••-••- Part of the SW4 of the NW4 of Section 10, Township 28 North, Range 19 West, St. Croix County, Wisconsin, described as follows, Commencing at the NW4 corner of said Section 10; thence S1320.9 feet along the E line of said NW4; thence S89 1322.97 feet to Point of Beginning thence S89'34'W 730.0 feet along the N line of said SW* of the NW thence SO'06'E 333.0 feet; thence N89 "34'E 730.0 feet; thence NO'06'W 333 .0 feet along the E line of said SW, of NW to Point of Beginning, except the N 33 feet for Town Road. 0• This is not .._ .. - homestead property. (is) (is not) Exception to warranties: easements, restrictions, ruts of way of record, if any. 7 Dated this day of . April _, I9b6 - �.��,'•' �'" rsl i \ (SEAL) (SEAL) __ _.... • Allen G. Lindh - - - - - .. (SEAL) - (SEAL) y AUTHENTICATION ACKNOWLEDGMENT STATE OF)QQeDDXM TEXAS L y Sig.;ature(s) - --- -- - --- -- -- --- ------- -- ----- -- ----- ------ ss. - - - --------------------------------------------- Travis -. _County. 19._.__. Personally came before me this - - - -- - -- - - - - -- -day of authenticated this -.. day of._ -_ -._ . aril -- - - - - -, 19 -.86. the above named ----------- - - - - -- --------•------- Allen .. Lin -- '- TITLE: MEMBER STATE BAR OF WISCONSIN --- • - - - - -- -- -- - - -'-- ` -' -- a (If not. - -- -- ... authorized by 706.06, Wis. StatsJ to me known to be the person _ who executed the foreeoin¢ instrument and acknowledge the same. •DFPARTaENT.OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: 1:1 Holding Tank El In-Ground Pressure ❑ Mound (If assigned) N E OF PERMIT HOLDER: A RESS OF PERMIT H LDER: INSPECTION DATE: � BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Na of Plumber: MP /MPR SW No.: County ( Sanitary Permit Number: SEPTIC ANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV, WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO OYES ONO BEDDING: VENT DIA. I VENT MATL.: HIGH WATER ROAD: 11PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. u. LINE: AIR INLET: YES ❑NO ❑YES ONO DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO IDYES ONO I DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. PROPERTY WELL BUILDING. JVENTTOFRESH (DIFFERENCE BETWEEN�� �a" LI "E AIR INLET. PUMP ON AND OFF) ❑YES ONO SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing p LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LENGTH NO. OF DISTR. PIPE SPACING. COVER a. INSIUE DIA.. #PITS. LIQUID l� TRENCHES. MATERIAL:+ DEPTH: BELOW PIPES TH A OVE COVER. ELEVR INLET E E�/ END DISTR. PIPE MATERIAL: PPI P E DISTR � �{ 15' r LINE ERTV WELL. BUILDING : AIR ��O�RESH ee 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. 1:1 YES El NO SOIL .`OVER. TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS. ❑YES El DYES FIND DEPTH OVER TRENCH'BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED. CENTER EDGES OYES ONO ❑YES ONO I OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: TRENCHES: MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING '. ELEV.: ELEV- DIA. ELEV. PIPES. DIA_: HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. OYES 0 N ❑YES ❑NO a COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL: BUILDING: LINE: OYES ONO OYES ❑NO Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) . DEPAfTMEJVT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SAWARY DIVISION I!ABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Property Owner: Mailing Address: e �r <.- Property Loc tion: City, Village or Township: County- 1 �Uj' /4S A / T Z"N/ R (or) W YO - =r ��/ C/'d 11G Lot ber: Blk No : Subdivision Name: Nearestmoad, Lake or Landmark: State Plan I.D. Num r: fil (If assigned) lY TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedroo s: 1 or 2 Family * State Approval Required. TOTAL NUMBER PREFAB POURED -IN STEEL FIBE NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PL RGLASS CE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: �E�= EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit 8 2 F El Alternative (specify) ❑ Seepage Trench Water Supply: t � Owner's Name as Listed on Soil Test Report (if other than present owner): Private ED Joint ❑Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name lumber: Signature c MP /MPRSW No.: Phone Number: ( 715 A 6 <SG Plum is ress: Name of Designer: �r = COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee Dame: IN APPROVED Sanitary Permit Number: x1 rL — v' ❑ DISAPPROVED O r Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink- Owner, Goldenrod - Plumber DILHR -SBD -6398 (N.03/81) US TRY, T Y OF R EPORT ON. SOIL BORINGS, + F '_'0 &BUILDINGS IND r DIVISION LABOR AND PERCOLATION TESTS (1 ) � Ulvr �� , DISON WI 53707 V3 P.O. BOX 769 HUMAN RELATIONS (H63.0911) & Chapter 145.045) OCT 19 198 _. , LOCATION: SECTION: WNSHIP NICIPALITY: OT". BLK. K DIVISI N NAME: 10 Tidy N /R/ � W TQ.r� Y COUNTY: WNE U R S AM A A C4Zz I 2v = 1zT. Rive USE DATES OBSERV IONS MADE I COMWERCIALR T O I g; esidence � �Naw ❑Replace I �O //G �� �, /Q �C+��}' RATING: S- Site sui table fo r system U- Site unsuitable for system 111 ONVE �Y . MOUN � �Y I N-G �VD � � ❑�L EIS �� G ,RECOMMENDED SYSTEM:loptionat) �J �$JC - C0AJ\1G If Percolation Teets are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)Ib), indicate: ( ly(1 Q s Floo indicate Floodplain eleva I� • , .jCD(L f3p0(L PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED INCHEH TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) B- ( /ov . 9 I�/ o �J E �, S ° �t B L L, / " 6 S t L, z4� Y (3 S L w� G R Gn i3 ., 4:; D S Ca► 7< ' J B- Z 88 ` /0-3., 7 4 8 ` , / `f " 13N S ; ✓r, Z �'� .� g N S L d tii� O rsra 4 a P L t. JUG /� n L w G 2 C a 4.. B- q , LSD / dl, o /l/ n/�: > z5v ��, �,,� I>� s, 47" u „ 1. 4, 12 j 'a L w 6R R. t C - 0 ( 3. /4" j &4 LS w,I& Q, B - tjp /al.Z ONE sm Mss 5 , 4.4" 13 I-, 50.., iS A L •n,� G,ra, $ g� LS w L`+a, IL "� �N a .I t. w /UR. /4" g.. ; . L .v bc,¢ gN SL w cat N , /4 "� r3 � Fit. �� PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PEBIO I PERIOD PER INCH P- e P- vn{. 3 /L P P• P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of lend slope. 1a (3 $ /�x_H �f—K .. s T IC SYSTEM : ELEVATION 9 8, 0 1st °4 IL Ir tN 1 o - —�� �, � . �� N � y �. � ; � fi o.s.. �� s N �� �� t� ti � 6 G � r � l � \ / r � N £ ,,, � � I °� � j I � ~ �� ,� r (� l � +" �`� 1 , �� r X � � i � S R �� Q) r o � � 1 %� 'r'r i" J v ; - -- -_ - - --- _���....�_�_._._ l � o � o © �� I 6 t �� r 9 � ( a 1 t ° ' � � i t io � � � � � � � � � ��. ._ ! f co —� --- p 1 � i �_ �� V � ^i ��� �ra rl-a qj a N � I E l ! J�