HomeMy WebLinkAbout042-1012-60-000 Parcel #: 042 - 1012 -60 -000 10/04/2005 04:27 PM
PAGE 1 OF 1
Alt. Parcel #: 05.29.18.76A 042 - TOWN OF WARREN
Current ,X j ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - COLEMAN, RON & DELORES
RON & DELORES COLEMAN
1118 105TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1118 105TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 39.000 Plat: N/A -NOT AVAILABLE
SEC 5 T29N R18W SE SW EXC CSM 5/1285 Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
05- 29N -18W
Notes: Parcel History:
Date Doc # Vol /Page Type
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/22/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 12,000 64,000 76,000 NO
AGRICULTURAL G4 20.500 2,500 0 2,500 NO
UNDEVELOPED G5 1.000 100 0 100 NO
PRODUCTIVE FORST LAND G6 16.500 24,800 0 24,800 NO
Totals for 2005:
General Property 39.000 39,400 64,000 103,400
Woodland 0.000 0 0
Totals for 2004:
General Property 39.000 64,100 64,000 128,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 312
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count'k. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar2ey�itNa.:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 1 UU11
COLEMA9, s 15 ALD Wk k 9illage Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: �+ Parcel TY4A210_:1012- 60-000
TANK INFORMATION ELEVATION DATA A9800189
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Lriction 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
DI MENSIONS DIMENSION
SETBACK
SYSTEM TO P/L BLDG I WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type Of CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipes) 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
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.)
LOCATION: WARREN 05.29.18.76A,SE,SW 1118 105TH STREET
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
i
v�i�'■'■R SANITARY PERMIT APPLICATION Burets of Building Water Divis
Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. Sr � x
• See reverse side for instructions for completing this application State Sanitary Permit Number
3i_ 1
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
1Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Pr rty Owner ame Property Location
5F1/4_54,) 1/4, S j T 7 Cl , N, R E (or&
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cit Nearest Road
❑ Village
Public L1 or 2 Family Dwelling - No. of bedrooms .2= — aCown OF CJ
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment /.Condo � - /� 0 � — C-
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 El 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. E] New 2 E] Replacement 3. ❑ E] Replacement of 4 Reconnection of
1-KrrA
5. Repair of an
------ System ________System - ------------ Tank Only -------------- Existing System Existing 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 DdSeepage 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) 9 Elevation
&Cfko Feet .,'51 Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Fiber- plastic Exper.
New Existing Gallons Tanks Concrete strutted Steel glass App.
Tanks Tanks
Septic Tank or Holding Tank 60a /pC o / ❑ ❑ 2 El El ❑
Lift Pump Tank /Siphon Chamber ❑ 1 1:1 1 El I E I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1 the undersi ned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
ame: (Print) mps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Santa tPermitFee (Includes Groundwater ate Issue Issuin Ag n Sign Ze (No Stamps)
Approved urcharge Fee)
Owner Given Initial �C D �. 4 0 1
Adverse Determination V /
X. CONDITIONS OF APPROVAL / REASONS FOR I APPROVAL:
S8D -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildi rigs Divi.i on, Owner, Plumber
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the � � residence located at: 5 % 54,J /"
Sec. j T ! N, R Town of ty4e ^ St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced Q,�,% M5 8
Did flow back occur from absorption system Yes No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: Ze
Construction: Prefab Concrete Steel Other
Manufacturer (if known) :
Age of Tank (if known):
�u
(Si ure) (Name Plea�6 Print
(Title) F (License Number)
(Date)
F orm to be completed d b licensed P ed
Y plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I
certify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over
outlet baffle).
Name y ` , Signature
e_
MP /MPRS
Wisconsin Department of Commerce - -SOIL AND SITE EVALUATION
Division of Safety and Buildings .�' y 4 Page of
Bureau of Integrated Services ` n'aeecsrd tc awith s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not es than 8 urt � r it in s�rea``Plan must County
include, but not limited to: vertical an '/ rAfetence point (BM),'4i�tion and
percent slope, scale or dimensions, rlliWarrow,�anq loca�on istar
an8 �� 4t' nearest road. Parcel I.D
i� h�� 1
V S , ftCiX — D I
APPLICANT INFORMATION Please pru )%fgforma R vie d y P Date
Personal information you provide maybe use . , "s*ondg"U1�sQjac�y4 .15.04 (1) (m)). /Q
Property Owner Property Location
R Govt. Lot s 1/4 S(J 1/4,S S T a E (or 1�
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
�IJL� a P% k)T 16 acct ( 715 )Q26 -555 W C.,_ V- ^ e- h I L D t S+
❑ New Construction Use: SResidential / Number of bedrooms c ik Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 3 00 gpd Recommended design loading rate bed, gpdfft trench, gpd/ft
Absorption area required bed, ft trench, ft2 Maximum design loading rate bed, gpd/ft trench, gpd/ft
tiSC "'t' , !'
filtration surface elevation(s) 'f . (D- ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material a N Flood plain elevation, if applicable ft
Eu = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
= Unsuitable for system S ❑ U ® s ❑ U ®S ❑ U ®S ❑ U ❑ S E, U ❑ S FA U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 ► C
1S.5 7S K P, f ^ O - nr, t,-
Ground s -31 ?. 5 `j I2`dY ��, _.__... a_ L. dM SbY_ ' -, - �J F
e ev.
W.—Sift. 31 -1 1 1 - 7 , S 19 L5 �y 1 vt L �, /� '
Depth to
limiting 75 / Q yr,-` J am,'
factor
-Min.
Remarks:
Boring #
Ground
elev.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
.v- 10
Address Date CST Number
6 aV
WK NINE
arm M
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning Department for new coastmctioa)
Parcel Identification Number
LEGAL DESCRIPTION
Property Location y., Sec. S _ T 29 N -R W, Town of ar��
Subdivision
Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # - 9 2 Volume SSl . Page # S6S'
Spec house ❑ yes P no Lot lines identifiable ❑ yes ❑. no
M y .- � /1.1•1��J6AA�L ]LL \ VaJ Y
O useandmandcna=: eofyourseptlesyst =could=mhisitspr n*utm fain =t011andlCwastes.ProperID�ance
pampmg Oat the septic task every $roe years or if by # licensed PanTeer. What you put into the rystem
can affect.the finictioa of the septic tank treatment stage m the waft-disposdlsysteni.
The PrOPertY owner agrees to submit to St Gone Zoning Depa rtmeat a certification form, signed by the owner and by a
P Journeymaaphm#x , restrietedplumberor a lic =scdpumpervedfying that (1) the on -site wastewaterdisposal system
IS is Proper operating condition andlor (2) after inspection and pumping -(if necessary), the septic -tank is hers than 113 full of sludge.
Ywe, the izad=igaed have read die above requirements and agree to maintain the private sewage disposal system with the standards
set fork herein, as set by the Department of Commence and the Department of Natural Reso urces,
sting that y= optic State of wrsconsm._ Certification
system has been maintained must be completed and returned to the St Croix.County Zoning Office within 30
days the three year expiration date.
SIGNAIVRE OF AP1111CANT DATE
OWNER- CEI2 MCATZON
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
P the described abov by virtue of a warranty deed recorded in Register of Deeds Office.
NA OF I:ICANT
DATE
« « « « «« Any information that is mis -repr rented may result in the sanitary permit being revoked by the Zoning Department"
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
t STATE BAR OF 'Mo I
WCUME14T No `+ CONSIN -FOR 'µ
;• { � 1104 "rr DEED
iR
E t i VOL 55 ,JO a T H;S SPACE REStRvEo F RECt3 Vk(A r PATA
t
t iUrGiSTERS OFH
1)# DEED, made between LO. l. T. I - f� S Slil�lr ilk3tl 'S _. ' i'
murph; and_ Jeannie _M. _Murphy. husband and �fe.a . and Jeannie __ ? St. CgC7lX C4.,1KiS.
Guardian,-of-Jams E._. Murphy - , an _incor►lpe,tent Roc'd. for Record *is3 -
Grantor 14arc' t 7
and _.RQn,_Qleman_and._D-.loreS A. COle_wn,_husband and wi_fe,.._.._ day of A.D. 1Q
at llsl(3 t,
1 ,
Grantee,
I t
Witnesseth, That the said Grantor for a valuable con;;derat ton ____ _�.. _ R
i lot
conveys to Granted the following described real estate
- County, i RETURN TO
State of Wisconsin: !
E� of SWk. Seca 5, T29N, R18W, consisting of 80 acres S_� —•
more or less. Tax Key • __...
This is _ homestead property.
(This deed is given in satisfaction of a land contract dated Jule 18, 1974 and recd -Jed ,#
at the St. Croix County Register of Deeds office on July 19, 1974, in vol. 513, pages
554 -555, as Doc. No. 323046.)
TRANSFER
3 Oe 00
FED
Together with all and singular the hereditaments and appurtenances thereunto belonging cw in any wise appertaining;
And IDuLs T_ Ro lf,•1am --, y - y l f�ntlie _� ► �"'�Y`Y
warren's that the title is good, indefeasible in fee simple and bee and clear of encumbrances except ea semen ts. - and xe= "
stri ctions -of— record
and will warrant and defend the same.
Executed at �R1Vt'r Fa �11i 1 SCOI IS_i_n this _ day of
SIGNED AND SEALED IN PRESENCE OF (SEAL)
Lou T.
C
rsEAL)
s E . _ 3PhY____.
IAI-.AoL If (SEAL)
Jeannie M. b hY____�._
,f
�i
g zAte S _ 4. M= _h�yt _ t & •1 821Ii,2 M. � livA�', 1
Gull,� 1
.i Signatures ot._jg T , Rolf,_ a sitiZip n J ames E. _Mu and Jearm _!!�CUphy,_. ggjba. -,i_
and�tife a en d ula e� -_ Murphy S � y r , clianszf_ James E. M�l xph - oMetcnt,____
authenticated this J_ day of _�yt;_,_. ___ , 14_77. .
C. M. Bye l c"
Title: Member Stcte Ba. of Wisconsin of Other Party
Authorized under Sec, 7n6.06 viz. _ - ---
to STATE OF WISCONSIN
ss '
_ County-
Personally came before me, this ___ -- - -__.__ day of
the above named
'l to me known to be the person_____ who executed the foregoing instrument and acknowledged the same.
F ,.
P
• AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP r� fw SEC. •-5 T ` /N, R If W
O. ADDRESS l . , ST. CROIX COUNTY, WISCONSIN.
.3DIVISION , LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
. t
_X 2 L _
:'TIC TANK(S) MFGR. , �� CONCRETE STEEL
NO. of rings on cover n - Dept DRY WELL
?NCHES NO. of width length area
:? no. of lines `z width length are .
depth to top of pipe
jREGATE ,�/�� ( ^�zJ 1,2 f
. a RATE 5 AREA REQUIRED AREA AS BUILT
_aciaimer: The inspection of this system by St. Croix County does not imply complete
- pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
tem operation. However, if failure is noted the County will make every effort to
ermine cause of failure.
:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SY5 EM.
`'INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER _3
1
Y
z -
- REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
S / *aAt P2.►n S ticj>D
NAME _ rownbh.ip w S$. Cno.ix County
Locat.ioxS& W Section
SEPTIC TANK
j
Size � gattonz. Number o6 Compartments
1 1 Distance From: Wet . 12% on greaten ztope it
Buitding it. Wettands fit.
H.ighwaten it.
DISPOSAL SYSTEM
Distance Fnom: wet q St. 12% or greaten stope it.
Bu.itd.ing OZ,D it. w ettand.6 F t.
H.ighwater - , St.
FIELD DIMENSIONS:
Wi dxh o the Depth o nochi b elow t.ite
Length o6 each tine ..� St. Depth o6 rock oven t.ite o2, .i n.
Number , o 6 tin ens Depth o4 tit e b etow gAade 30 in.
Totat Length o4 Una� it. Stope of trench L in pen 100 it.
Distance between tines Co i t. Depth to bedrock.
Totat abz orbt.ion area st2 Depth to groundwater
Required area S� 6t2 Type o4 Cover: ape n Straw
PIT DIMENSIONS:
Number o6 pits Ghavet around p.itss yea no
Outside diameter it. Depth below ,inlet it.
Totat ab�s orbt.io a �t .
A
Are %equi.red it n+
INSPECTED BY TITLE
APPROVED ,DATE S 1979
i
REJECTED ,DATE 197_
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH
• 4. , . P.O. BOX 309
MADISON,'WISCdNSIN 53701
CC . REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: 5 1/4,3 4,Section 5-,T2 lV, R ISE (or) W,Township or Municipality /`rrr Gn
Lot No. , Block No. County 5r O ix
/ /_Subiivision Name
Owner's Name: ire, I? ..,/5/ m `--s��e 4 `'_/ (�J�
Mailing Address: _// ../l , ke,a.) 1l / G 4 m D n 4 �'► s
TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW " ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: (SOIL BORINGS 41 -- c-3 -77 PERCOLATION TESTS / --023 — 77
SOIL MAP SHEET 5/ SOIL TYPE /C4- es
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P—r 345 a e /3 doC 19‘,744z i 1119 3 ‘ i , s
P 3� i el20 3 e X IS
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED�J/ ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B_-
/ 2r2 /(f 1// 7 /2. P."— I-S ?, f'�•C.-
A 72 = I 7 7.1 3✓' '=r_5 G�,.._ /9',,.
B. 3 7 -, I ' 7 7� /'�3 75 y�yf._&" /�
''� 7 2, I r 7 !s'� 7 I d'" s/ / $ / ^e"
B 5 7z , , 7 7-2. G ' 7-5 is " - 5i/ . 3y'= ',-
G 72- , ► 77,--, d - 75 i " — .,i/ . y- ,.--.
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of syitabl areas. Indi e numbe of s9 uare feet of abs r ' n area
needed for building type and occupancy. I.- 34V7 a scale
or distances. Give horizontal and vertical reference poi s. Indicate slope.
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I,the undersig ed, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct
to the best of my knowledge and belief.Name (print) 4/ e.-A cot—el )4 of 11L fliS Certification No. / 7�)/ 3
Address n_y JA/eu, // i4 ma Yp/5_
Name of installer if known
�
CST Signature����'t�-"'`/ ,4 r
COPY A— LOCAL AUTHORITY
~ State and County State Permit #
P L- 7-5
1 ` � Application Count Per 't # '7 .
�� Permit lication Y `
.s for Private Domestic Sewage Systems County •¢'c�
*DENOTES STATE APPROVAL REQUIRED //
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
•
d h ram/c/ 14/1 v We— An 0 e7.• X, 4, ike- fl' Uri eiL o h 1�i>S
B. LOCATION: 3 /4' . '/4, Section ,5 , T?-g N, FVi �( (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ,9/P/E:n.
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family v Duplex No. of Bedrooms 3 No. of Persons 3
D. TYPE OF APPLIANCES: Dishwasher Lc/ES NO Food Waste Grinder YES LSO # of Bathrooms_L
Automatic Washer L--''VES NO Other (specify)
E. SEPTIC TANK CAPACITY / Total gallons No. of tanks 0"--*^'-4--
*Holding tank capacity Total gallons No. of tanks
New Installation i. Addition Replacement Prefab Concrete
*Poured in Place Steel Lam" Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) , S 2) , S' 3) , ( Total Absorb Area G 2. r sq. ft.
New 1/Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_
Seepage Bed: Length 5 .I Width /p•/ Depth 3 G " Tile Depth V ' No. of Lines ' —
Seepage Pit: Inside diameter Liquid Depth Tile Size `/
Percent slope of land ! — 7 % Distance from critical slope
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 /f/c h cg fr. ,/ V// /1 A iii_SC.S.T. # / 9/_3 and other information
obtained from / (owner/builder).Plumber's Signature %,dGza�Lc/ ) MP/MPRSW# /8 s_2 Phone # AV G 5Y3,'
Plumber's Address t
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space Below - FOR DEPARTMENT USE ONLY rsii
Date of Application 4- $ O/79 Fees Paid: State / , (' Co ty ' % D e T/-5 t� 7/
Permit Issued/Rejeeted (date)/ --f13C'r7`l Issuing Agent Nam '
Inspection Yes r'` No Valid# Date Rec'd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1/76