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HomeMy WebLinkAbout042-1022-10-200 J A- 4 STC - 104 AS BUILT SANITARY SYSTEM REPORT ADDRESS ~ OWNERJ(),ryFCE SUBDIVISION LOT SECTIONTN-R_,(W, Town of__ ST. CROIX COUNTY, WISCONSIN . PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7 70~~~ /Q Scr e INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. n f " --BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK 'INFORMATION Manufacturer: U~c~S Liquid Capacity: Setback from: Well House_ :s~' Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: _ Length 9p Number of trenches Distance & Direction to nearest prop. line: le5- Al Setback from: well: 9s House-917_ Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system_ 2/~ ~~,as V, s Existing Grade Final grade DATE OF INSTALLATION: , --2 " PLUMBER ON JOB: LICENSE NUMBER! INSPECTOR: ~,Cc 3/93:jt Wisconsin Depdrtment of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitaruP,gttvgja: Personal information you provice may be used for secondary purposes [Privacy L S.15.04 (1)(m)). L 25 y 4 6 U BOON ~deBL "WAt2KL''N llage Town of: State Plan ID No.: CST BM Elev.: 1L Insp. BM Elev.: BM Description:w~~~~ Parcel _h8 1022-10-200 TANK INFORMATION ELEVATION DATA A9700276 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO 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 Friction System TDH Ft oss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER Model Number: 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 Depth Over Depth Over I 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 8.29.18,SE,SE 1020 110TH STREET LOT 4 .c")~~~ Q s'fi' `yP'wt Plan revision required? ❑ Yes ❑ No Use other side for additional information. /d , '-<fa r a SBD-6710 (R.3/97) Date In ector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: l DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouNTY ri 'IV # STATE NI q & 0 -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ 3(~'GI/ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY W R PROPERTY LOCATION T _S %4 t/4, S , N, R (or PROPERTY OWNER'S AILING AQDR LOT # BLOCK # I f _Z/ ( 1 14 CITY ATE A 3 d ZIP CODE PHONE NUMBER SUBDIVISION NAME OR 2S§NUM8E44_-, L 11 318 II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE NEARES ROAD ❑ Public [Z 1 or 2 Fam. Dwelling-# of bedrooms 3 P R EL AX NUMBER_ III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 !~Motel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.,w New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. ATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/da ft.) (Min ./i ch) ELEVATION 2 9,19 PACITCITY Feet , Feet A VII. TANK in al Total Site # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank F77 Ll Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum er's ame rintU-n Plumber' Si atu e: ( rP/MPRSW No.: Business Phone Number: Plu ber's d ress (SSttree ity, State lp Code): n IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ent Si ure (N m pd) XApproved ❑ Owner Given Initial GU Surcharge Fee) Adverse Determination /G,06 ~/Z 7 97 4 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS i { 1. A sanitary permit is valid for two (2) years. 2. Your sanitary per nit may be renewed before the expiration date, and the time o` rE ^r d it 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 owne-.ship or plumber requires a Sanitary Permit Transfer/Renewal Fotrn (r F31) 6399) to be submitted to the county prior to installation. 5 '-')nsite sewage sys°ems must be properly maintained. The septic tank(s) ml,at be pUrraec )y a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local ccde adcr,inistrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family/ Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, 'econnection, 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 ga Ions number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material.::omPlete for all septic, pump/siphon and holding tanks for this system. Check experimental approval oily If tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with app,op,iate 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 tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil ;bsorption 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-6398 (R.11/88) i r x so. '~3S f~/'Sr~ ~0S-7 S2,z - X9/' s r /~k 1.2, a o ~ztf k is,~ ^ Nc4 11wo I ~5 y8` i i i I I i I - • Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page -4 of Bureau of Integrated Services in with s. ILHR 83.09, Wis. Adm. Code 8 9 Attach complete site plan on paper not less x 11 i es I Ian must County / include, but not limited to: vertical and hori n e M), and percent slope, scale or dimensions, north , and I (i est road. Parcel I.D. # I APPLICANT INFORMATION - e -Miathi4 lion Reviewed by Date Personal information you provide may be used f ry Pu r taw, (1) (m)). J Property er ZONINtiOPRGE Property Location S Govt. Lot 1/4 1/4,S 8 T ,,R (or11~F Property Owner's Mailin Address Lot # Block# Subd. Name or C Citytats Zap Code Phone Number ❑ City Village 21 Town Nearest Road New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpol?_L_'~___trench, gpd/tt2 Absorption area required _bed, ft2 6 D trench, ft2 Maximum design loading rate bed, gpd/fF -fi-trench, gpd* Recommended infiltration surface elevation(s) (as referred to site plan benchmark) Additional design/site considerations Parent material '2~-_/l Flood plain elevation, if applicable it rU== Suitable for systeConventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank Unsuitable for system ® S El U m S E] U s ❑ u 0 S ❑ u ❑ S flu ❑ S .9 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/112 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 Ground elev.. Depth to limiting factor zz~in. Remarks: Boring # 13 42LI Ground elev. Depth to limiting factor >AL _in. Remarks: CST VNae lease ri ~ Sig lure Telephone No. Address Date CST Number Z", -27 SOIL DESCRIPTION REPORT PROPERTY OWNER Page =2- of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 4j h; Ground elev. aft. _ Depth to 1 / / limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) • ~1 I S, 40 7-/s=97 3 1 -571 so sel ~iP6i4psxr~ ~ Wisconsin Department of Industry, SOIL AND SITE E V A L U AT I Q"F P O R T Page of I +Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. 7°►d 'Code COUNTY S Cr,2o/X 'Attach complete site plan on paper not less than 8 1/2 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. ~A~o2 /~oZoZ APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION AEVIEWEDBY DATE PROPERTY OWNER: PROPERTY LOCATION ' !/old Cl GOVT. LOT 5 E 1/4 !5E-1/4,S T N,R 18' qft W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # `SUED. NAME OR CSM # 1aa /av CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OrOWN EAREST ROAD o Wk~, 5 Oa3 ('745) " N [A New Construction Use [.Q Residential/ Number of bedrooms 3 ro [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe A,' /4 Code der'IVed daily flow' 6-0 gpd Recommended design loading rate /VP bed, gpd/ft2 ~ Z trench, gpd/ft2 Absorption area required _N P bed, ft2 a;1 ~56 trench, ft2 Ma)dmum design loading rate _,~bed, gpd$. Z trench, gpd/ft2 Recommended infiltration surface elevation(s) ~J It (as referred to site plan nchmark) - Additional design / site considerations r t ou3 % !u'c' , Parent material Flood plain elevation, if applicable /UM It 7-=Unsuitable able for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK fors stem ❑ S 0OU ®S ❑ U ❑ S ®U ❑ S O U ❑ S 011 ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench D-3 A w a/ S/ 2 m m Fie C S' rr~ .5 1 A, . 2 7;9J I7IY FR 3eo q/p ..z Ground a C Z m s6 k ~i S I .2 3 elev - % CA) Sc/ / m sik M - "Z 3 Depth to limiting factor 1 5 t © R IE4 e-4 la Remarks: Boring # :.,.:.,..:...4. . w 1 D--3 /0 -2h Sc~C ,Z m r C S 3 m ,5 . z.W I v EP i s e-o P 0- 3 2-3 10 y/~! ~ C rn sbk )'1'I P, es t m Fz ::,3 Ground ele z ft. 43 5-oe e sI / In S6~ yY1 )~s 1 s' 3. N S" 2 S 4 rn s P94 AT Depth to limiting 7/'Y ~r412 3/-Y (2) 5j'- )m M tv F ` - .3 04/ fac . ~rl Remarks: o I/ Q CST Name.=Please Print® * Phone: it S 6 8 --23(o-'-l Address: .9/0 'E' ln#?L'~e7 Y/- O !/I p G. S S Signature: ~ Date: ~ /fD CST Numbe~s, PROPERTYOWNER Ior- S Oiu6IdOSOIL DESCRIPTION REPORT Page of PARCEL I.D. # C Ada - /Oa a --/0 Depth Dominant Color Mottles Texture Structure Consistence Bouidary Roots GPD/ftBoring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Be, Tmrxfi w Cl m / 5' r~'I S 3 Ems) ~ ~,,C ,+e S eo fvp Z K z -3-/3 / 5 V C Z SD~ n4 CS Z~ , Z . 3 Ground 3 / 3 - /e, A2 ft. - ~ 5 .C s / s6k P211 Al llcko 1-F Depth to 8-S(o 7 S2 s~~ Se O Ir7 i''~ L' S TU limiting factor 1o fib 5 2 3/ ~S,C / m s6~ /f?iC Remarks: s li O(\ d Boring # l c~ 5 Ground elev. ft. Depth to limiting factor Remarks: Boring # S Ground elev. ft Depth to limiting factor Remarks: Boring # 4~{ IRA Ground elev. ft. . Depth to limiting factor _ Remarks: SBD-6330(R.05/92) I y4 C) 17 f Wm f F ~ Z Z ~ Z a~ Qj I O W e' U 1 t / ~t~ I v; cr 441 OL o f L X7 \ 1 S~ \ co 0 1 aft E - ~ d r 8 T C - loo r This application form is to be completed in full and signed by the ,owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. -----------------------/---WO ~l Owner of property Location of p operty 1/41/4 , Section TAN-R_W Township Mailing address Address of site Subdivision name Lot no. Other homes on property? Yes_ --'\I_No Previous owner of property ~y Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable?-yes No Is this property being developed for (spec house) ? Yes _ ~ No Volume J,?/ ~ and Page Number 2-:12-as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. and (we own ' the proposed site for the sewa a ~disposaltslstem) orr Ie(we) obtained an easement, to run the above des gibed property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signature of Applicant 4CO-ppe~lic~ant 7- 20 Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS 3 S- Co S~. -:5 ' n sl~9 PROPERTY ADDRESS 1ZP~ ~JS (location of septic system) Please obtain from the Planning Dept. CITY/STATE ® PROPERTY LOCATION 1/4,_ 1/4, Sections T .~9 N-R_Zg _W TOWN OFD. ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP~y VOLUME / , PAGE, LOT NUMBER 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 licensed septic tank pumper. What you put into the system can .affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation-prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 5541413 STATE BAR WARRANTY WISCONSIDEED M - 1982 DOCUMENT NO. VOL 1219PA017 _Thomas .1. Sullwold and Nona M. Sullwold, hBCJtt17"'' -husband and wife, as survivorship marital JAN 2 2 1991 property, 10:30 A. conveys and warrant, to William Booth Booth husband and wife a uT and Karina A xLvorship marl*a1 "'tP'~1VuvCa Dr,;,erty i. THIS SPACE RESERVED FOR RECORDING DATA the following described real estate in St. Croix NAME AND RETURN ADDRESS State of Wisconsin: County PARCEL IDENTIFIC TION NUMBER (See Attached Exhibit "A") NSFER This is not homestead property. (is) (is rot) Exception to warranties: Dated this _ 20th day of January A.D., 19 97 (SEAL) (SEAL) • Thom J. Sullwold , • Nona M. Sullwold (SEAL) I it j AUTHENTICATION ACKNOWLEDGMENT j Signature(s) State of Wisconsin, St. Croix ss. I+ authenticated this day of 19_ County I~ Personally came before me this 20th _ day of I -January the alo Thomas J. Sullwold and-Nona named ~I ' ' ii !I husband and wife II TITLE: MEMBER STATE BAR OF WISCONSIN I~ (If not, authorized by $706.06, Wis. Scats.) i to me k wn to be the person 'I ~ who executed the foregoing 'I instru t and acknowledge same . THIS INSTRUMENT WAS DRAFTED SY ; B enda Poulin ! i • r VOL -P 19 PAU 1.19, r EXHIBIT "A" Part of the Southeast Quarter (SE1/4) of Sec. 8-T29N-R18W, Town of Warren. St. Croix County, Wisconsin, described as follows: ; 1,ot 4 of Certified Survey Map recorded in Vol. 11, Page 3185, in the office of the Register of Deeds for St. Croix County, Wisconsin. That certain parcel of land located in the Southeast 1/4 of the -Southeast 1/4 of Section 8, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, more fully described as follows: Commencing at the Northwest corner of Lot 4 of that Certified Survey Map recorded in Vol. 11, Page 3185, of St. Croix County Certified Survey Maps, the POINT OF BEGINNING, of the parcel to be herein described; thence S0001511211E (rerecorded bearing on the West line of said Lot 4) a distance of 354.081 ; thence S89044148"W 200.00'; thence N00015112"W 354.08'; thence 889044'48"E 200.00' to the POINT OF BEGINNING, containing 1.626 , acres, being subject to easements of record. .e t 4 s Ii yyRRt 1 h Y' J ~,j~j. f 1 4 , yt, W`4 PRIVATE SEWAGE SYSTEM Safety and Buildings Division REVIEW APPLICATION Bureau of Building Water Systems /Hayward Office LaCrosse Office Madison Office Shawano Office Waukesha Office 209 W. 1st St. 2226 Rose Street 201 E. Washington Ave. 1340 E. Green Bay St. 401 Pilot Court, Ste. C Rt 8, Box 8072 La Crosse, WI 54603 P.O. Box 7969 Suite 300 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785-9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606 Phone (715) 634-4804 Fax (608) 785-9330 Phone (608) 266-3151 Phone (715) 524-3626 Fax (414) 548-8614 Fax (715) 634-5150 Fax (608) 261-6699 Fax (715) 524-3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans/information. Your submittal must be received at least two working days prior to the appointment at the office where your review was scheduled. Please call any of the listed offices if you need help filling out the form or have questions on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)]. 1. APPOINTMENT INFORMATION - If you have scheduled an appointment, fill in the information requested below to save time: Appointment Date Review, r Name Ian Identification Number -ad- i 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here: Project m County ❑ City ❑ Village Town of. Project Location / GOVT. LOT 114 114,S T N,R (ore - ' ' 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type ` (include new and existing tanks) A ❑ At-Grade Up To 1,500 gallon septic tank ....................................$110.00...................... H ❑ Holding Tank 1,501 - 2,500 gallon septic tank .....................................$120.00...................... M C, Mound 2,501 - 5,000 gallon septic tank .....................................$160.00...................... N ❑ Non-Pressurized In-Ground (Conventional) 5,001 - 9,000 gallon septic tank .....................................$200.00...................... P ❑ Pressurized In-Ground 9,001 - 15,000 gallon septic tank .....................................$300.00.........,............ 0 ❑ Other: Over 15,000 gallon septic tank .....................................$500.00...................... Up To 1,000 gallon dose chamber 70.00...................... 7f_~ Building Type (check one): 1,001 - 2,000 gallon dose chamber 80.00...................... D Dwelling, 1 or 2 Family 2,001 - 4,000 gallon dose chamber ...............................$100.00...................... P ❑ Public Building 4,001 - 8,000 gallon dose chamber ...............................$120.00...................... S ❑ State-Owned Building 8,001 - 12,000 gallon dose chamber ...............................$140.00...................... Over 12,000 gallon dose chamber 160.00...................... Up To 5,000 gallon holding tank 60.00...................... Code Derived Daily Flow gpd 5,001 - 10,000 gallon holding tank ...................................$100.00...................... Over 10,000 gallon holding tank ..................................$150.00...................... ❑ Check if Replacing Existing System Experimental System (additional one time fee) ................$300.00...................... Revisions to Approved Plan 2 60.00...................... Petitions for Variance: Setback ...................................$100.00.:.................... ❑ Petition for Variance Site Evaluation .........................$225.00...................... Plumbing $225.00...................... Revision 75.00...................... ❑ Groundwater Monitoring Groundwater Monitoring - Per Site 60.00...................... (other than a proposed subdivision) ❑ Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring 60.00 Subtotal: .5~e-~ Priority Review: Enter same amount as Subtotal: MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: Jac - 5. SUBMITTING PARTY INFORMATION Telephone No. (include area code & extension) Coma y Name Co a Person i No. & Street Address or P.O. Box City, Town or V' lage, State Zip Code Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. 2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals. NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. SBD-6748 (R. 03/96) < ! l m m D O ! N 0) Z Z n y V O mO O Z; 2 D y w O v !Q -u r~EBzmo=iA m Ipy°Ip' S D m-Xo ~ a,~ ~ a ~ Opt ~a~Co (a A a ; .1 a yEsc m o 0 3 v A~R o i' A IE U 30 2 '00 x p 3 F 8 _ Q o 0 n = z Zvi 3z a m v p~ a ((~1~~J 2 I=il m o k d (ry~~ m a n N 0 'i 01 3 m P Z' .r °c a x "1 O c m o ; c 1O+ uu m m 2 S T m Z D« o Zi 17 mO n V y w m a o c w o T O c 240 0 :3 o94 DO~~ m D ; w m o e n! x O A A Z °cmmm< 4c) 0 m °Q m r - 1o n m J 0 53 um; X a O N d n c y Z 3 mo•~ u m ~mlNa si nSu m O G) 10' a mcg °._t c' X°n~n 3mw x 3 a rn O Q3m_~~ momma O's a^ y oO -i v ? c m agg m p mry p 3 a -n a O d>: a 3{~ g'm o O m E 3 mo°c°cm- m0 33u n~a ~2 0 0 Z $ E s 3gcgl7 CO va13 0 O m bi a 00 Z ww t'v 11 ~ Pm$ C . 3 0 V, w Aw m N w No z 2 4 3w c °cm~go NO m v 1 O y o G) 'O A m O C O m A N C g m. N C W A O S S `b 3. 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O n~ ~y 3 C CL =r (D U) (D N y d m ~ 53 O m m n(D Q co) y Z 0 m' 3 7 m Qm CD m y-0 0 3 3 O m m 3 c ~'c O ON~~ ~m mac 7 m m N N U Om r1 'o GO = W to O 3 1 = 3 N CD m (O O n.. 0 m S m -o c o co -o a) (moo o N y O . m c a m O m n CD o C 7& 3 G) N p N 7 CO N O N N Q~ XV y 3 Q j .'i+ - 3 C=I(D W 0 (D CL - 0 m m Z 0 CL cn y N' 7 C Q - C 7 tmn 0. N y N Q m cc 3 c cp y Private Sewage System Plan Index/Checklist All plan sets should be legible and permanent copies, organized into sets, bound with staples and covered by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each set is signed. Your cooperation expedites your plan review and shortens plan entry time. Plan ID # Owner' Legal Description Ad City/Viflage/TA" County r Contents Comments/Special Instructions Page # Included Two copies needed for all plans 1 Plot Plan 2 Plan View/ Q Return by Mail 3 , 4 oss Ste• Q Fax Letter to (County) (Submitter) of j°rkssuer Circle One and Provide Fax ( ) 5 - 6 12 - Call for Pick-Up: ( ) 7 Q Other I, the undersigned, hereby certify that the Seal (if applicable) plans and specifications submitted herewith were prepared under my direction and control. PI igner Licatsolegiatration # Address City State r~ Signature For Office Use Only Attachments: Application Soil do site evaluation Fee Needed for Holding Tank Submittal: One copy of notarized holding tank agreement. (Originals to County) Needed for At-Grade Submittal: Original signed and notarized Application for -Use of an At- Grade" County on-site One additional set of plans SBD-10268 (N.01/96) tec~t0 'J "t, sit 0 /o?S ~ i $i A~ 1 MA 4yl Zi- Asti a s'r______7 /oq r Designer.- Date. Non-Woven Filter Fabric 4" Observation Pipe ~Dis1riDUlion Pipe ASTM - C 33 Sand Topsoil G Alter. Pos, of Force Main E !S D t % Slope Bed Of -2 Force Main Plowe d Drain Rock From Pump Layer D 16, • ~ Cross Section Of A Mound System Using E -J, &_2 A S*d For The Absorplion Areo F c A Ft. H B Ft. I ,2,0_ Ft. J _LL Ft. K Ins- Ft. Alternate Position L Ft. of Force Main k' 9 Ft. J 14~Observotion Pipe B -K A o ~Force PMain W o From Pump ump 3 p° Distribution Bed Of I/2"- 2 Pipe Drain Rock 1 4 Observation Pipe Permonent Morker Pipe or Rods, Pion View Of Mound Usinq A -B-rd For The Absorption Area PAGE,,_OF~ r PERFORATED PIPE DETAIL and DISTRIBUTION PIPE LAYOUT Perforated Schedule 40 PVC Pipe End Cap Jatyaarce ale Holes Located On Bottom Are Equally Spaced End Cap 4 4 ' Last Hole Should Be Next To End Cap Owner's Name: p 9-::? feet Plumber/designer's Signature: x inches y inches Date: License No.: Hole Diameter inch Lateral Diameter inch(es) Force Main Diameter inches Holes per Lateral S~ feet. Invert Elevation of Laterals Page of s b 7 r cn a. 0 . m m JPx ~ m = En W m ~ o M ~ro I< ~ N ~r N m E7L Q rt r• o 0 0 M ►0 n m 1 (<D N :j N rt ~ ro m b - to Q& N (p It 9 w ~W 0 rt M 1j. M \ :3 0 O~rrtt d w r• a 0 IV t 0 rt M r• L a . w n w a m ` PAGE OF Z PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VEAIT CAP 4~ VENT PIPE WEATHERPROOF _ APPROVED LOCKING JUIJCTIOIJ BOX MAWHOLE COVER WITH ZS' FROM DOOR, VJAIWING LAI&F-L WINDOW OR FRESH IL MIU. AIR INTAKE GRADE ~ y.. MIAJ. I I * te'MIU. C0IJDUIT WAIN. ~ 11l IMLET PROVIDE I AIRI"IGHT SEAL I I i I \ APPROVED JOIIJT A I III APPROVED JOIIJTS W/ PIPE I III W/ ' PIPE EXTEHDIUG 3' I II ALARM EXTEUDI►1G 3' 0gT0 50LID SOIL I II ONTO SOLID SOIL I I ON I, C i LLEV. FT, ~ PUMP - b OFF D CONCRETE CLOCK RISER EXIT PERMI-ITIED OQLy IF TAUK MAUUFACTURE:R HAS SUCH APPROVAL 3" APPRoVE.a £flEDCING undcr T-i%r-IY, SEPTIC E SPECIFICATIOUS DOSE TAUKS MAUUFACTURER: WMSER OF DOSES: PER DA-4 TAMK SIZE: GALL /OATS DOSE VOLUME ALARM MAUUFACTUKESi:S~r INCLUDING 6ACKFLOW: GALLONS MODEL IJUM6ER: CAPACITIES: A= ao:: 11JCNE5 OR 7 GALL01J5 SWITCH T,JPC: INCHES OR - '59_ GALLOWS J" y PUMP MAQUFACTURER: _ C. IWCHES OR 1_3'3 GALLOU,S MODEL MUMDER.+~~ D- INCHESOR 5L2 GALLOWS SWITCH TYPE: AJOTE: PUMP AMD ALARM ARE TO DE INSTALLED OW SEPARATE CIRCUITS MI►JIMUM DISCHARGE RATE .~5 GPM~l__qo VERTICAL DIFFEKEIJCE DETWEEU PUMP OFF AIJD DISTRIBUTION PIPE.. .15.e FEET + lkJIMLIM METWORK SUPPLY PKEE/SSSURE~~. . , . , . , . 2.5 FEET FEET OF FORCE MAIN Y, ~1LF/Iporr.FRtCTIOU FACTOR.. •n / FEET TOTAL 0' AQA~MIC HEAD 1~= 1 1- FEET IIJTERMAL DIMEIJSIOQf. OF TAUK: LEWGTH ;WIDTI{ ;LIQUID DEPTH SIGIJED:__ _ LICENSE NUMBER: DATE: Performance zpuiDmersime U E m . Curves Pumps 61 ~ METERS FEET 90 25 MODEL 3885 80 SIZE 3/4" Solids WE15H 70 20 WE10H 60 -WE07M 15 50 W E05H 40 10 30 WE03M 20 WE031 S 10 0 0 L 0 10 20 30 40 50 60 70 80 90 100 110 120 (IPM 0 10 20 30 W/h CAPACITY [(b]GOULDS PUMPS, INC. S&ECA PkLs NEW METERS FEET 120 MODEL 3885 35 110 WEISHH SIZE 3/4" Solids 100. 30 90 25 70 20 60 -i~~ O f. . WE05HH 50 ±EH~-7 15 40 10 30 20 S 10 0 0 0 10 20 30 40 50 •60 70 80 90 100 110 120 GPM l .1 1 , 0 10 20 30 m,A► CAPACITY • 19W Gould& Pumps, Inc, EMcpw July, 1905 C]8Rs -y Aw 7Sr l~/r j 7v )C;20,4 q~~ ~ \ 5 ~ ~ . ~~i,,~ 7 J ~'/f/~~' ~ S ~ `~~G~ ~f / / -f/' . e. .r CL a c &d 4y JI f t S' ry 77- } x~ ,A T ~ L F 4 r: PU- , •i { , x p ry 7-7 t~O AY ~I .r. .RTC . Y ' P 7 s ,if h ~ ~-r - ;x•! x,9+..1:.---~---- ~ a P, , . _ ` ct ~ _ rwil•5. r.~.-' '_"'_'t `.per r AUUVVLS, WL J•-1 VLF 44 1 , 6 I 1" ROVED LOT 2 , 33 33 : I . . I h ti11 i q 2.500 ACRES 1 OI , p`j'~ ' IO9,900 so. Fr. I C ~O i• a ?.164 ACRES EXC. ROAD R.O.W. al o c a I q tmm cowry Q , II 130 :•',s 811 pa'"` Plam'a ~aviv~0landt~ l S 09 44 IB"W 135.50' IR = V 3T 9. BT ` 56J.31 tJ J e 170• 4 k o ROAD SFTBACM, LINE ' • ~ f 211 f119~1~ ~J.'t •.•id az Lor 44 nJ J p P.4bO ACRFs I Q~ Q y W - 108, goo so, Fr. ^ qI h W `J q W1 2.1 B1 ACRES Erf. R040 R-O. W. I hl ^ 12 W 9?, 173 S0. CT, i/A/Y1. S :891 41' 48 •'W 435. go- lPB. OI' 214, 7' 53. 91 CO• maaaf Is 30T.J6' I ♦~aa`A\GGON~ P,I Dated: Sept. 26, 1996 o Indicates 1" x 24" LO r 4 l jLAU N Z"M iron pipe weigbing -1-- I ` rn 1 W M RPHY CC 1.3 = 1. 1.13 lbs • /lin. u) ° 2.500 ACRES o l dP . i ; ft. set. Q v 109,901 So. Fr. a ALLS,,, W% 4 *Indicates 1" n 2.099 ACRES £XC. ROAQ R.0 .W. WISC.,,..~ iron pipe found .R 91, o! 11 so. Fr. 2 y, el ~~i 9F S ► Indicates 'j 3 ` I driveway 0 ~ . location. ll,~ n Laurence W.. Murphy This instrument ~ ~ Registered Land Surveyor drafted by Q x - - - _ ! a Laurence W, Murphy Q. 5,~ Pot' j 100 • ~ I R~ 249.63' 117,9 S B9 • 41' IB "W 307.56' O SCA&C , 100. UNPL A TIED LANDS re co*. Sre.a. rFpu. 4 is w. 0 2S' 4o' 1001 /SO' 290, 300 ^ ~lCGU,vrr SvRVFroR's MON.1 SHM 1 OF 2 VOLUME 11 PAGE 3185 ii v '_:~0 uc1 h n ~C(d f d ®G 'I 4/ ~J 0 Tea 5 ~Q f ® l~ r U~ ~c , ` j l rv n ~c lG 4 ~ /~lG✓' I h arc l f v~~o sal, 61nd wAe' e k'5e DEC. -10' 96(TUE) 11:09 ED1NA REM RIVER F f TEL:715 425 0331 P. 001 I f TOO '39dd ddiX3 M rr z y G I i