HomeMy WebLinkAbout012-2005-30-200
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
162
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Sellent, Beverly & Walter Erin Prairie, Town of 012-2005-30-200
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
04.30.17.5876
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
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 0 No Fa] Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / /
Location: 1758 Cty. Rd. T New Richmond, WI 54017 (SE 1/4 NE 1/4 4 T30N R1 7W) Jewett Mills Lot 9-15BIk 93 Parcel No: 04.30.17.587B
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? E Yes 0 No m
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No.
County anitary Permit Appftapq ST. CROIX COUNTY WISCONSIN
p~ In accordwith C apert 12 St. Croix County Sanitary QYpa CANNING & ZONING DEPARTMENT
Persgnq~~11knation u provide may be used for secondary oses RON COUNTY GOVERNMENT CENTER
~0 ~ R ~N I ivacy Law. S. 15.04(1)(m)j 1101 Carmichael Road
iG~~~ONGOFF~G Hudson, WI 54016-7710
(715)386-4680 Fax (715)386-4686
' G complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
Sanitary Permit # ❑ Check if revision to previous application
1. Application Information - Please Print all Information Location:
Property Owner Name
, c-r ~ Wet et f 4e-r ~ e_1 1,~ ~ 1 /4 ' 1/4, Sec
e ii,, N, R / qN~,
Property Owner's Mai' g A dress Lot Number Bis J. 3 L4 9~9
Cit , tale _Zip Code Phone Numer Subdivision Name or CSM Number
y~,tll~ ~(c~l M6'no~ d
II Typ of Building: (check one) D amity p ViIL4
llage Town of
or 2 Family Dwelling - No. of Bedrooms:
Public/Commercial (describe use):
PAO,-
0 State-owned Nearest Road
I, Type of Permit: (Check only one box on line A. Check box on line B if applicable) 17% r2~
Parcel Tax N mr(s '
A) 1.0 Repair 2.X Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation
Sanitation
B) p~ QO- d ,4 k„ Permit Number Date Issue
IWXState Sanitary Permit was previously issue`s
IV. Type of POWT System: (Check all that apply)
t Non-pressurized In-qri ound ❑ Mound ? 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Mound A+0 t•'
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other
LDesign e ❑ Aerobic Treatment Unit ❑ Recirculating
Treatment Area Information:
w (gpd) 2. Dispersal Area3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Require Proposed (Gals./day/sq.ft.) (Min./inch) Elevation
7j~t
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
5gd
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
ibility Statement
igned, assume responsibility for repair/reco nenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
Keq
required for terralift repair or the'nstallat of non-plumbing sanitation system.
a nt Plum ign r s s)• MP/MP S No. Business Phone Number
/5=~W-dre s (Street, Ci State, Z' ode
'g° Use Onl
Sanitaary Permit Fee Dat Issu d IsSig ture ooved se ~7~~
CJ /
a5i~
IX. Conditions of Approva
l/Reasons for Disapproval:
SYSTEM OWNER:
1. Septic tank, eAIkwmbd kaf~ and
dispersal cell must all be services / maintained
as per management plan provided by plumber.
Z Al 60,=k requirements must be maintained
ea * appow* code / tirdmaf.
WATER AND SEPTIC INSPECTION REPORT
Inspection date: Owner:
Property ddr s
The following is to be completed by a licensed plumber. The intent of this form is
solely to identify the functioning status of the septic as of the date indicated
above. The inspection of this septic system was based upon a surface inspection
and did not involve any excavating or chemical analysis.
On this day, a water sample was taken from (specify location where
sample was drawn) and submitted for testing.
On this day, the septic was inspected and found to be functional.
On this day, the septic was inspected and found to be NON-functional
as follows:
- -
Signed, a License number:/--'c o
Firm Name:
Address: Telephone:
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Olr~ siff-ve-
Mailing Address 0~~~a
Property Address t'~ Cj:c j ~ ~ 13 ~r J-t yK 1A 1 SC/o C?
(Verification re uired from Planning & Zoning Department for new construction.) -71 City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location 1/4 , 1/4 , Sec. , T N R W, Town of
Subdivision Plat: , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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 Planning &
Zoning Department within 30 days of the three year expiration date.
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.
Numbe of bedrooms
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 09/07)
800 7
8
TX:4 37990
920914
BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
08/18/2010 12:01 PM
EXEMPT N/A
REC FEE: 30.00
3.00
CERTIFIED SURVEY MAP COPY FEE:
2
LOCATED IN THE SE1/4 OF THE FRACTIONAL NE1/4 OF PAGES: 2
SECTION 4, T30N, R17W, TOWN OF ERIN PRAIRIE, ST. CROIX
COUNTY WISCONSIN, BEING BLOCKS 93,94 & 95, THE VACATED
ALLEY WAYS AND PORTIONS OF DISCONTINUED STREETS
THAT ABUT SAID BLOCKS IN THE PLAT OF JEWETT MILLS.
fOdUl PEE®L1 I ~i I I z o
aS CfX..roll 99 ~q
~.Id i I V2
co M. 4 N~
EAST LINE OF FRACTIONALNE114
~ v nw. 01 NOt'4T10'E 2323.51' ~ Z
L ~OUM[)! TRUNK HIGHWgY "T"
N01'41'10'E 2119.11' 1 I 1O
m N01r1'10"E 204.40'
I I SOI.41-10W 430.64
LEGEND 131.50' .00 233.14' ~
{r} - INDICATES SECTION CORNER MONUMENT I ^ ` g N
(AS NOTED) I w
0 - INDICATES 314' X 16' RE-BAR SET WEIGHING o i
1.51+11S. I LINEAR FOOT SET g~, I 5
p - INDICATES 125' IRON PIPE FOUND ®+I ~ h ~ ~ ~ ^ * : GRI~ B G S
® -INDICATES 1' IRON PIPE FOUND N _ EW$ CHMOND t
WI }
Owner Lots 1 & 2: I o w '4 s'~•..l„•"..•• ~O
Walter & Beverly Sellent , 2 G o N I O URV
E k oP
~-.t-_
2027 Hwy "46" c
New Richmond, WI 54017 s STA
W p~~T~Ey
t-------- o
Owners of Outlot 1:
I S01'41'10W 242.25'
Matthew & Erin Klanderman ,2 soti4rlo'W 131.50'
I
x,
I qpz~o
41 RE ONA W
E 1.4919 w
NOTE- EXISTING DRIVEWAYS CAN
STAY UNTIL SUCH TIME AS LOT 1 I I I N a
IS DEVELOPED OR A DWELLING IS z
BUILT ON LOT 1. W t I I 3 rn F w
NY I O O ~ W
u~ O -°A/E®_ _ p~0P I I a z
0
EASEMENT NOTE' THE EASEMENT - -t r - - - - g _ _ - - _tD I I w j a z 6
SHOWN HEREON IS TO SERVE AS w
THE ACCESS TO OUTLOT 1 AS + tuo p F
WELL AS LOTS 1 & 2 AS SHOWN. 8 I I I _ ~b
LOT 2 WILL ALSO HAVE EASEMENT M59 r
RIGHTS OVER THAT PORTION OF w w N i
LOT 1 LYING EASTERLY OF A m i w w z w
NORTHERLY EXTENSION OF THE ~i I to fit: °
WEST LINE OF LOT 2. THIS 41 og 0
1
EASEMENT IS INTENDED FOR I I S ? w
INGRESS AND EGRESS TO LOT 2 N R ww
AND FOR NO OTHER PURPOSE I Y7
I I za~vaPI]
~ nu inn nn-nv.r-n \ '11 I w
(awl
CERTIFIED SURVEY MAP
LOCATED IN THE SE1/4 OF THE FRACTIONAL NE1/4 OF
SECTION 4, T30N, R17W, TOWN OF ERIN PRAIRIE, ST. CROIX
0
COUNTY WISCONSIN, BEING BLOCKS 83,94 895, THE VACATED
ALLEY WAYS AND PORTIONS OF DISCONTINUED STREETS JOS H W z
THAT ABUT SAID BLOCKS IN THE PLAT OF JEWETT MILLS. * = G
DESCRIPT/ON. ;NEW RIG MD
A PARCEL OF LAND LOCATED IN THE SE 114 OF THE FRACTIONAL NE1/4
SECTION 4, T30N, R17W, TOWN OF ERIN PRAIRIE, ST. CROIX COUNTY, WI l_%.°«...°"° .COQ
BEING BLOCKS 93, 94 8 95, THE VACATED ALLEY WAYS AND PORTIONS OF 10 SUM
DISCONTINUED STREETS THAT ABUT SAID BLOCKS IN THE PLAT OF JEWETT
FURTHER DESCRIBED AS FOLLOWS: ~OIO
1
COMMENCING AT THE E 1/4 CORNER OF SAID SECTION 4; THENCE N01°41.10"E
204.40' ALONG THE EAST LINE OF THE FRACTIONAL NE1/4 OF SAID SECTION 4;
THENCE S89°5929W 49.47' TO A FOUND V IRON PIPE ON THE WESTERLY
RIGHT-OF-WAY LINE OF COUNTY TRUNK HIGHWAY "r AND THE POINT OF
BEGINNING; THENCE CONTINUING S89°59'29W 940.59' TO A FOUND 1" IRON PIPE
ON THE CENTERLINE OF DISCONTINUED JACKSON STREET; THENCE N01°41'10"E
459.00' ALONG THE CENTERLINE OF DISCONTINUED JACKSON STREET TO A FOUND
'1" IRON PIPE ON THE CENTERLINE OF DISCONTINUED FIRST AVENUE SOUTH;
THENCE S88°1 8'50"E 330.08' ALONG THE CENTERLINE OF SAID DISCONTINUED
FIRST AVENUE SOUTH TO A FOUND 1" IRON PIPE; THENCE CONTINUING ALONG
SAID CENTERLINE OF DISCONTINUED FIRST AVENUE S86°55'54"E 30.01' TO A
FOUND 1" IRON PIPE; THENCE CONTINUING ALONG THE CENTERLINE OF SAID
DISCONTINUED FIRST AVENUE SOUTH S88'1953"E 580.10' TO A FOUND 1" IRON
PIPE ON THE WESTERLY RIGHT-OF-WAY LINE OF SAID COUNTY TRUNK HIGHWAY
T; THENCE S01°41'10"W 430.64' ALONG SAID WESTERLY RIGHT-OF-WAY LINE TO
THE POINT OF BEGINNING, CONTAINING 418,087 SQUARE FEET ( 9.598 ACRES)
MORE OR LESS AND BEING SUBJECT TO ANY EASEMENTS, RESTRICTIONS OR
COVENANTS OF RECORD.
SURVEYORS CERT/FICATE
I, JOSEPH W. GRANBERG, PROFESSIONAL WISCONSIN LAND SURVEYOR, HEREBY
CERTIFY THAT BY THE DIRECTION OF WALTER AND BEVERLY SELLENT AND
MATTHEW AND ERIN KLANDERMAN, OWNERS, 1 HAVE SURVEYED AND MAPPED
THE LANDS SHOWN HEREON IN ACCORDANCE WITH OFFICIAL RECORDS, CHAPTER
236.45 OF THE WISCONSIN STATUTES AND THAT THIS MAP AND DESCRIPTION ARE
A TRUE AND CORRECT REPRESENTATION TO SCALE THERE OF.
THIS INSTRUMENT DRAFTED BY: JOSEPH W. GRANBERG S-2295
DATED THIS 4TH DAY OF MARCH, 2010.
GENERAL NO77CESTATEMENT.-
THE LOT SHOWN AND MAPPED HEREON IS SUBJECT TO STATE, COUNTY, AND
TOWNSHIP RULES, LAWS AND REGULATIONS ( Le., ACCESS TO PARCEL, WETLAND
RESTRICTIONS, MINIMUM LOT SIZE, ETC) . BEFORE PURCHASING OR
DEVELOPING ANY PARCEL CONTACT THE ST. CROIX COUNTY ZONING OFFICE AND
THE APPROPRIATE TOWN BOARD FOR ADVICE.
NOTE NO NEW LOTS HAVE BEEN CREATED THE PURPOSE OF THIS MAP IS TO
JOIN AND RECONFIGURE PORTIONS OF THE ORIGINAL PLAT OF JEWETT MILLS AND
TO RECONFIGURE THE BOUNDARIES SOLD TO THE KLANDERMANS AS RECORDED
IN VOLUME 2730, PAGE 82 IN THE ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
TOWNSHIP AND COUNTY APPROVALS ARE NOT REQUIRED PER STATE STATUTES
AS STATED UNDER 236.45 (2) (3) . REFER TO DOCUMENT NO.
FOR DEED REFERRING TO RECONFIGURATION OF LINES BETWEEN THE SELLENTS
AND THE KLANDERMANS.
~ I I I I I I I I N I I I I I I !III ! I I
I
8015242
State Bar of Wisconsin Form 2-2003 Tx :4011690
WARRANTY DEED 928850
DocumeotNumber DocuumsName BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED, made between Walter A. Sellent & Beverly J. Sellout 12/16/2010 11.57 AM
("Grantor," whether am or more), REC FEE: EXEMPT##:9
: 9
and _ The Walter A. Sellout & Beverly J. Sellent Revocable LivialiTrust 30.00
PAGES: 1
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant
interests, in ST. CROIX County, Wisconsin RO001~"'a'~"e'
That portion of the Southeast Quarter of the Northeast Name and Return Address
Quarter of Section 4, Township 30 North, Range 17 West, Walter A. Sellout &
Town of Erin Prairie; further described as Lot #I and Lot #2 of Beverly J. Sellent
46
Certified Survey Map # 920914 filed in Vol. 24, Page 5724. M7 Hwy
New RicAmoad, WI 54017
Subject to easement as shown on the Certified Survey Map, and
to a Right of Way along Easterly Line of Lot#2 as well as any 012-2005-02-000
other easements, restrictions and reservations of record, 012-2005-30-000
municipal and zoning ordinances. 012-2005-40-000
012-2005-40-100
Parcel Identification Number (PIN)
This IS NOT homestead ply,
(is) (is not)
Nov z o o
Dated 23
(SEAL) . 4, (SEAL)
• • Walter A. Sellent
(SEAL (SEAL)
• *.Beverly J. Sella t
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
STATE OF WISCONSIN )
authenticated on ss.
ST. CROIX COUNTY )
• Personally came before me on _ v 4,01
►t ~crZ
TITLE: MEMBER STATE BAR OF WISCONSIN the above-named A6-
J-54WQAtV :Z
(If not,
to me known to be th n( who executed tie foreg
authorized by Wis. Stet. § 706.06) instm t d ackno 1 ed the same. g
( 7 a -7
THIS INSTRUMENT DRAFTED BY: Q
•
A tcOR1 amt Notary Public, to of ;in
KL"It ndUfM(is peiman txpires: 2 SE~""'I-q.)
(signatures may auftee s are not
NOTE: THIS IS A STANDARD FO A M .
V10011 RM SH LD BE CLEARLY IDENTMED.
WARRANTY DEED O 2003 STATE IsA MJIN FORM N0. 2-203
• Type now below signatures.
1 of 1
1
AS BUILT SANITARY-SYSTEM REPORT
OWNER TOWNSHIP SEC.l QN-RJZW
ST. CROIX COUNTY, WISCONSIN.
ADDRESS
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
W. EVLRYTHING WITH -IN :T OF Sysnt9 ~
- Ltd
I dt a 0 or, the A roe j
SC 11:
BENCHMARK: (Permanent reference Point) Describe:.'/
Elevation of vertical referen a point: Slope at site:
SEPTIC TANK: Manufacturer: A s e Liquid Capacity:
Number of rings on cover ^Tan manhole cover elev do
Tank Inlet Elevation: Tank Outlet Elevation: "
PUMP CHAMBER
Manufacturer: Number of gallons _
Number of gal. pump set or a cycle. gallons; total capacity of-
distribution lines gallon: size of pump head;
gallon per minute horsepower. ran name of pump
and model number
Type of warning device--
HOLDING TANK: -Manufacturer Number of gallons
Elevation of manhole cover
DEPAR. MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR &`HUMAITRELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
IN CONVENTIONAL DALTERNATIVE State Plan LD.Number:
(
Holding Tank D In-Ground Pressure 1:1 Mound
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
t . ~ IF
p. - [ _ 1,P ai Al u
BENCH MARK (PQr anent reference point) DESCRIBE IF DIFFERENT FROM PLAN: _ REF. PT. ELEV.: CST REF. PT. ELEV.
Nwn-f Plumber: _ MP/MPRSW Nn. County: Sanitary Permit Number:
SEPTIC TANK/HOLDING TANK: 5 ,
MANUFACTURER LIQUID CAPACI V. TA KIN ET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COV
~I - O ED: PROV DE9
7 ES LINO NO
BEDDING: VENT DIA.: VENT MATL HIGHWA R NUMBER OF ROAD: 1PROPEFrrY WELL: 11111-111\11, VENT TO FRESH
ALARM / FEET FROM f LINE J C~ AIR IN
144ES LINO ! c - j ❑ I NO NEAREST I
D SING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY DUMP MU PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
T PROVIDED: PROVIDED:
EYES LINO EYES LINO DYES LINO
MBER OF PROPERTY WELL BUILDING VENTTOFRESH
GALLONS PER CYCLE: PUMP, `NocZT
E ZONAL 7NU
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLEr
PUMP ON AND OFF) LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil mois vre at he ept of plow g FORCE 1 [,,AMETIR MATERIAL AND MARKING
t
or excavation. (lf soil can be rolled into a wire, crra§tru ti n shall cease u til MAIN
the soil is dry enough to continue.) l/
CONVENTIONAL SYSTEM:
NIDTH L TH NO. OF UISTR. PIPES ACING COVER INSIDE DIA -PITS LIQUID
BED/TRENCH TRENCHES NrIAL: PIT DEPTH
DIMENSIONS
BE LO - W PIPES IILL Of PTH T 4 PIPF DISTR. PIPE DISTR. PIPE MATERIAL. N ISTR. NUMBER OF PROPERTY WELL: BUILDING. VENT TO FRESH
ABnOOV/E COVER II IIgV. INLFI ELEV. END/ 1P' FEET FROM LINE. f AIR~jLET.
oC~ 9Qi~ g.16 S iT I NEAREST- GOf~ OJ
MOUND SYSTEM: L- &
e
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 4e, certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the eria for um sa TIONS MEASURED.
EYES NO
SOIL COVER TEXTURE PENMAN T MARKERS OBSERVATION WELLS
ES LINO EYES LINO
DEPTH OVER THENCH BED IDEP1H OVER TRENCH BED D P;TH/F O OIL A SODDF SEEDED MULCHED.
CENTER EDGES
EYE LINO DYES LINO DYES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
.'VIDTH LENGTH NO F /'L ATE AL SPA ING: GRAVEL DEPT BELOW PIPE FILL DEPTH ABOVE COVER
RED/TRENCH TRNC s:
DIMENSIONS
MANIFOLD PUMP IFOLD ISTR. PIPE MANIFOLD 11 RIAL JNO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
-LE V.. ELEV. A. LEV.. PIPES. DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION I ,TOLE SIZE HOLE SPACING DRILLE C RECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
J EYES LINO - - DYES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF ,LROPERTY JWELL: JBUILDING:
FEET FROM LINE:
EYES LINO OYES LINO NEAREST
4 4 s
'C
i
_ 9 5
7 ~t l
Sketch S n7, l Retain in county file for audit.
Rever Sid . ?
SIGNATURE ; ~ / TITLE
DILHR SBD 6710 (R. 01/82) /
DEPARTMENT OF APPLICATION .
INDUSTRY, FOR SANITARY SAFETY & BUILDINGS
DIVISION
LABOR 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.
Pro arty Owner: Mailin _;,ress: j7
Property L6-cation: County:
'/4 r '/4S iT N/R It (or) W
Lot Nu)nber: Blk N Subdivision Na Nearest oa , Lake r Landmark: State Plan I.D. Number:
(If assigned)
Y A OF BUILDI G
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
L9 1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: 1
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): U~ New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as isted on Soil Test Report (If other than present owner):
12 Private El Joint El Public
I, the undersigned, hereby assume responsibility for installation of the pri sewage system shown on the attached plans.
Na of Plumber: Sign r MP/MPRSW No. Phone Number.:
< ) =
.1
dies
Plum be s Address: Name Des ner:
A
COUNTY/DEPARTMENT USE ONLY
Sig ature of Issuing Agent: Fee: , Date: Sa itary Permit Number:
y J ®•APPROVED
~LaA ❑ DISAPPROVED
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)
ILDINGS
NDUSTRY,NT OF REPORT ON SOIL BORINGS LCAND SAFETY & B DIVISION LABOR A:N
P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
LOCATION: SECT
40
N: TOWNSHIP/Mb'NtCtPAl TY: LOT 113LK. O.: SUBDIVISI N NAME:
r WI
I /T so
A~ _1911/11/7t (or)
COUNTY:' O ER'S BUYER'S A E: AILIN ADDRESS:
Z-41 ' s3 f y 7
USE f DAT S OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION] R NS: 1PERCOLATION TESTS:
Residence RNew ❑Replace
FLi 1~11 16
c'
RATING: S= Site suitable for system U= Site unsuitable for system A4j1__ /141,
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: TIS TEM-IN-FILLHOLD NG A K: RECOM E DEDSYSTEM:(optional)
Q s ❑u R 1 s ou ou ❑ s ®u I
If Percolation Tests are NOT required ]DESIGN RATE: SY TE_ EL 7LFI y por tion of the lot is in the
under s.H63.09(5)(b), indicate: dplain, indicate Floodplain elevation:
i'
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
134 / ,v
3
47 3
B- It
AIA_ >
B- 7 _ , s y rr
rN
° / 7 ?
B-3
o T_ ~
/410 1 46A AZ J > o ? ,
' i
B-7 7 8,1
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. FERIO 1 PERI D2 PERT PER INCH
P " . 716
P- I 3
P-
P
P_
PLAN VIEW: 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 land slop.
SYSTEM ELEVATION
T
4d E
l _ :'t/J 5 m mm
F '
3
)4j r C9 0~10
'ELI"
a a
7~ gJ ,l° v T, o ray
T/
l
- 3°~