Loading...
HomeMy WebLinkAbout032-1048-70-000 oo p $ M _ 3 0 's o N p e> 0 c C c c o II ~ i I N c rv; L o •3 o ° V 0 r -p X O N O O b co M O L tY U N Y U N C c Z f6 N C _ N 7 F C LL 0 CO LL O LL O a co rn O p a _0 Q IL Q 3 Cl) 3 co V Z 4i Z U1 Z O `O chw am am F- cn c O c Z -ac o z N p d 2 d' O C I 0 ~ Z I N O Cl) N N O N ~ ~•J a a) Q) a N N N • N U) .c N U) .NC O ~y Q n ro Fi O O o N Q o N Q !E z co z z co z o N _ z w c E 4) E N _ (D 1 N £ 2 E _ m_ N in la l0 U') CD 4T 0. m CL CL Cl L N N ° N L N N 2 to co cn co (n (n co w _E m w z 3 3 3 a a 3 3 3 a s 0 Z •N E a a a N a a a N a a~ ~ (M~ ? O O CO 0 (D (D N ~~1• N J U U) rn ° U)N Z N } O P-) (D 7 O ~\l c 0 N a0 N N N (D 11c) Q rL.+ _ N ~ .L... m _ m a" W U) 0 (D N Q Z N Q SJ LO 7 w U) 3 O O O Cl) N C 0 co M N c r:+ °o Q 3 -i c y -i ° c E N m 0) Q d M° c c ° c c °m u a o 0 0 CL r- 'O N N Cb N~ co a E m Y E O C O N ° c N O N O C O N ' O L O L "3 I~ "0 N aO O N F- -0 01 co 0 7 Z' ~ N c7 E 0) rn N E O S N O N U • L' O U) Y N O N~ Z Y N O z N U) O ~ rA d m Ea ;,a #6 a L a w a T r~• a m Z m y c c D c `~1 A U a 2 0 in v 0 N U A STC 104 AS BUILT SANITARY SYSTEM REPORT OWNER o1J K 1 T4 b ADDRESS 3Z0 iJ JMjLV IUG- ~,p~'S SUBDIVISION / CSMg tfOL OroS LOT SECTION 1'7 TIN-R Lg 40 Town of :54/pC-p,~56~-r ST. CROIX COUNTY, WISCONSIN P VIEW SHOW EVERYTHING W THIN 100 FEET OF SYSTEM A ~1 I T _ Up 12 T ~7J ~.oP L~ nab INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i t BENCHMARK: to QIP& ON Lje,ST Re L zw- ALTERNATE BM: Tb P U 494- VCK SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Are ~Ks Liquid Capacity: /006 Setback from: Well House Other Pump: Manufacturer Model # Size Float seperation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM width:``!, Z Length Q Number of trenches Distance '&Sirection to nearest prop. line:,eAs-r 2-7' FR-orh k 7~ P~2DP ~i~ R Setback from: well: House sq_ Other ELEVATIONS Building Sewer S, ST Inlet. 2 ST outlet PC inlet PC bottom Pump Off Header/Manifold ~0 Bottom of system 4 Existing Grade Final grade L, DATE OF INSTALLATION: /~0l PLUMBER ON JOB: y LICENSE NUMBER: INSPECTOR: 3/93:jt Wnsconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST* CROIX Safety and Buildings Division 4GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village Town of: State Plan I o.: KING, RON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: Lo 61 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic JJ y,.,~ y / iJ - Benchmark Dosi _ , C ~'rr1, J 37' JG~, Aeration Bldg. Sewer Holdin St/Inlet S ~a' ~Sl S"f? TANK SETBACK INFORMATION St KP Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 25 NA Dt Bottom f1 Dosing NA Header / Man. Aeration Dist. Pipe ~S oJ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GP TDH Lift Friction y L oss Hyea Force ain Length Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt No. Of Trenches PI No. Of Pits Insid i Depth DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LE NG Map r. SETBACK INFORMATION Type Of n~.,.C{n~ O AMBER Model Number: re~^G OR UNIT System: DISTRIBUTION SYSTEM Header/ Distribution Pipe(s) / x !Dole Size x Hole Spacing t To Air Intake Length t0! Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys s On y Depth Over „ Depth Over xx Depth Of x Seeded/Sodded fjrV u lched 21 Bed/Trench Center Bed /Trench Edges Topsoil ❑ Yes No Yes ❑ No J COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET-17.31.19W, SE, NE, LOT 5, 226TH-AVE M Plan revision requYred? ❑ Yes []-Niu- Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No agwo . Safety and Buildings Division ~•'■~i~r'3 SANITARY PERMIT APPLICATION Bureau of Building Water System: 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 n than 8 1/2 x 11 inches in size. r Y, a • See reverse side for instructions for completing this application State Sanitary Permit Number a( 939Z The information you provide may be used by other government agency programs ❑ Check it revision to previopplication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prgrty Owne Name Property Location 1`d N G 5,E1/4 jVg1/4r S T 31 , N, R /CIE (or) 4i Property Owner's Mailing Address Lot Number Block Num er za s -W VJE Apr 5 5 u n Name or CSM umber City, State Zi Code Phone umb r SubdiviV10 # R► Moo kl= 'Dt1 (?l5>24'33'Y C 9 E II. TYPE OF BUILDING: (check one) ❑ State Owned E3 ❑ ViI ll lj age oad SpjA~RS~T ST Public Cff 1 or 2 Family Dwelling - No. of bedrooms Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo Q 3a _ IDAV8 - 70 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. E] Replacement of 4. E] Reconnection of 5_ F] 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 NSeepage 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 Require(sq. ft.) Proposedsq. ft.) (Gals/da/sq. ft.) (Min./inch) Elevation 14 Sd C //,s Feet r?'~ Feet TANK Capacity VII. INFORMATION in gallonTotal # of Prefab. Site Fiber- Exper New Existing Gallons Tanks Manufacturer's Name Concrete strutted Con- steel glass Plastic App Tanks Tanks ~ Septic Tank or Holding Tank /000 W 6i K1t ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber. ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Z lumbe 's Name: (Print) Plumber's Si nature: (No ps) MP/M&6VV'K_0.: Business Phone Number: Plumb Address (Street, City, State, Zip Code S ~0 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (Includes Groundwater ate Issue I Sul g Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6396 (R. 05/94) DISTRIBUTION: original to COnnly, One cnpy To: Safety & Ruildings Di-,ion, Owner, Plumber ' r ' INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3_ All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator, or the State of Wisconsin, Safety and 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 on line A. Complete line B if permit is for tank replacement, n-.onnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information- Provide all information requested for numbers i through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, -Turn :Eir of tanks and manufacturer's name, indicate prefai, or site constructed and tank material. Ccr iplete fci , ptic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks receive experimer t.product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number v it approari,i- arefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. LO(n;,;elF pl~lr~- spt~i f lCations not smaller t-an R /L X 11 !nchts rT1U t i?G s tted t .'i+? : , inty- 1 one plans must l _,UU. =f {flan, drawn '.O scale UI Vfl ill comp k.tIe ~G..nerlslvrr ;GCati.s Ing tank(s), septic id pump or siphon Sr'Stc'R?S, r -Ofdre _~,/..9', „t J the building served; {Jt v(1 3. r1" a'.0f .i -SO volume; ~ E • ~ _ F-mF _ r; ci,a. r .r:, m_, ~r; Ji cross section rur ,e sou absofptio_ t .1 ~~auired k:y D soli (estdatel C r, a sizing information_ GROUNDWATI=P SURCHARGE 1983 Wisconsin Ar t 410 included the I eation of surcharges (fees) for a numhr rE2_~i, ated pr .~c:i which can effect groundwater. The monies collected through these,,urcharges are used for monitoring groundwater r vntarmna!io nvestigations and establishment of standards 3zo SAwr6\tL. LAur- AYT 6 PIEW RjCtlMoN1D, WJ' 610)7 SE VN NE Vy 5EC. 17 `r 31, NR 1°I W SoMFR5rr TWNSIIIP L. OT $ SCALE o ! ' o n~F © SUED 2LEV wa fVo, WELL 0 1~0 00 Ii II I I' 7Z SGO i 4 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide maybe used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Prope Owner Property Location l Govt. Lot 114 114,S T N,R )?"(or N Property Owner's Mailing Address Lot # Block# Sub . Name or CSM# 4 1 30 Z" 7X City State Zip Code Phone Number El city [:1 Village Town Nearest Road 1 All' 0 New Construction Use: Residential / Number of bedrooms c Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow - gpd Recommended design loading rate bed, gpd/fF trench, gpd/ft2 Absorption area required -bed, ft2 Z:5:11) trench, ft 2 Maximum design loading rate _Z _bed, gpd/ft2trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site/considerations Parent material 0U- z "W Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressu71Z AT-Grade System in Fill Holding Tank U = Unsuitable for system Rs ❑ U R S ❑ U S❑ U S ❑ U ❑ S ® U ❑ S O 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. S/h. Bed Trench Ground elev. Depth to limiting factor Remarks: Boring # f Ground elev. ft• Depth to limiting factor Ain. Remarks: CST Name lease Print) Signature Telephone No. ys- 7~ Address Date - CST Number ~sC~ n _ ~G PROPERTY OWNER 2eW SOIL DESCRIPTION REPORT Page l-.-~' of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground _ 7, .9 e lev. s - - Depth to limiting factor Remarks: Boring # J-5;- -7 - nnGrroound el ft. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. Bed , Trench Boring # 2:' g Ground ele v. v ft. Depth to limiting factor 2:W in. Remarks: Boring # I Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) .moo S~ - -s~ ~ 4~! f 1::z4 J) P ~ ~jNrt i L 7S" J/evs,~ o? yo I b CERTIFIED SUR Located in part of the Southeast. one-quarter of the Northeast one- quarter of Section 17, Township 31. North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin.* OWNER: River Hill Family Trust LEGEND Gary Gifford, Trustee FOUND ST. CROIX CO, MONUMENT 452 280th St. • FOUND I" IRON PIPE Osceola, Wi. 54020 0 SET I" x 24" IRON PIPE WEIGHING 1,68 LBS./LINEAR FOOT. UNPLATTED LANDS SCALE 1" = 200' NORTH LINE OF THE SE V4 OF THE NE 1/4 N870 34'02"E 694,60' 200 100 0 200 294.93 399,67 OF n~s C in c0 m Z'T n Z z ~Q• DOUQLAS J. I wfi (n ° ZAHLER ac o r a 7 w w 8 * 8-2145- OR m m HUDSON, * A T m 193,860 SO. FT. 180,036 SO. FT, w~s />w. z -1 4.430 ACRES 4.133 ACRES JV '4 O` O=m "V r'mZ t0 SUo N p m m I W ° m 1n °s>-4 N 1' 0 1 zZ BUILDING 5 O z N SETBACK--_y: A o 1 m W 4 N I~ 'n 0 0 w 6I, 9sS•• 1 S69a 59 32 7 6' 9 a'V m \ m 3 SS S~ 1 A - a T10.3• EXISTING 66' ROAD EASEMENT- TO BE 0 2'F DEDICATED TO PUBLIC I-P I N to II i0 S N m _ DETAIL - m z Co. N) II - m Ln A I ~ I N' 5 0 6 3 0) N87149'39"E I' 0.42' 234,729 SO. FT. ON• 225,003 SQ. FT, N 5.389 ACRES 5.167 ACRES n NE CORNER cn 0 N - SECTION 17 a) OD 47 (0 I O u 1-~ u IG) {Oil 1 J 1 _ I n EI/4 CORNER :4 SECTION 17 M T31N, R19W ro 284.62 409,99' S 870 49'39" W 645.43 S870 49° 39" W 694-61' SOUTH LINE OF THE NE 1/4 x m N w UNPLATTED_ LANDS_ Z m z This instrument was drafted by Douglas J. Zahler N . ~i a• y m a STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St Croix County OWNERMUY1ER. J. G MAILING ADDRESS 3z,:? S.awmi~L Xfr PROPERTY ADDRESS 6 7N v~- (location of septic system) Please obtain from the Planning Dept. CITY/STATE ►2a~6~SET +~_L PROPERTY LOCATION _S 1/4, IV 5 1/4, Section / TOWN OF ~xm C~z s ~ T ST. CROXK COUNTY, WI SUBDIVISION LOT NUMBER S CERTIFIED SURVEY MAP G z ~ 5'3 , VOLUMz PAGE -,?&.s/ , LOT NUMI1ER s- 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 disposal system in accordance with the standards set forth, herein as to 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 ex iration date. SIGNED: DATE: = j St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 UJ 1!6!jU IU:lj U' 1U. ..,r..,. S T C - 100 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. Owner of property /)oti'AzZ `j: Location of property sc 1/4 lc- 1/4, Section 1 ,T 3 N-R !9 Township S~~n~2S~T Mailing address ~5b ceacr W~ Address of site Subdivision name iU i° e4ies Lot no. S Other homes on property? Yes X No Previous owner of property T,~ 4. G,eu,VV--i Total size of property Total size of parcel Date parcel was created ..luny ZZ x%/F3 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? 'Yes No Volume and. Page Number z~sl as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION TIM FOLLOWING: A WARRANTY DEED which includes a DOCtTMENT 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 T (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 that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described 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 App scant Co-Applicant I Date o Signature Date of Signature t ~ J ST.\TE BAR OF WISCONSIN 1482 NVARRANFY DEED e,% n DOCUMENT NO. ~ 1100Pa;-211 PEGI, TER S ' Timothy A. Grunow and Tammy-K. Grunow, hus~~:.A $T. CRC;X r' an tom,- - - - ~ MAR 1 1 1996 amc}s and warrants to `Ronald J. -Kin, + at 9:30 A. ki - re,3 SIACE "_,SERVED ~Ga --COP:, NG JATA NAME AND atTURN ACDRESS the foilowinK descrihed real estate in St. Croix A, orney Kri 'tina Oland untnn, r + SC7Ie of W;sconsin: P 0 BOX 359 HUDSON WI 54016 032-1045-70 _ PARCEL -ENTIF.CAT:ON NUM6Eq Part of SE1/4 of NE1/4 of Section 17-31-19 ~-'escribcd as follows: Lot 5 of Certified Survey Hap filed July 27, 1993, In Vol. 119", page 2651. This is not homestead property. )OM (is not Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of Marc , AD . 19 96 (SEAL) u t Sc t X~l y~(ilt~ (SEAL) Timothy A. Gruntxa Tammy K. ~runow 7 ' (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Timothy A. Grunow, State of Wisconsin, Tammy K. Grunow ss County + authenticated this S day of t Larch 19 96 Pero Wally came before me this day of W- the above named Kri sti eta nal.and TI7 LE: MENIBER SLATE BAR OF WISCONSIN (If not, authorized by §70,506. Wis. Stats.) no«n to be the person _ who executed the Iorcgomg _ xne and acknowledge the same. Wiscgnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: 'Laborand Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village a Town o : State Pla KING, RONALD J X CST BM Elev.: Insp. BM Elev.: BM Description: SOMERSET Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. A irl to ntake ROAD Dt Inlet Air l Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding ::J Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Head 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 DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Moe 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 xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET.17.31>19W, SE, NE, 216TH AVE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau Building Water Systems 201 E. Washington Ave. i 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 8 112 x 11 inches in size. 5-~- ~r O l • See reverse side for instructions for completing this application State Sanitary Permit Number .7-5-9yQa The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pro erty Owner Name Property Location - o ~ L~ 114 KC 1/4, S 1'7 T N, R 19 E (or)0 Property Owner's Mailing Address Lot Number Block Number L E Ate' S City, State Zi Code Phone Number Subdivision Name or CSM Number Nt-W R, fe vy ~yal7 (715 )Zq -3st y o'( w II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest R a Public ❑ 1 or 2 Family Dwelling - No. of bedrodms rA Town OF S~ 6 `7Q ST III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) p 1 ❑ Apartment/ Condo 0 3~~ 76 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. K New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an _____System __--_-__System_----- _______TankOnly______---- Existing System _________E---------- 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) 4 ~1 Elevation ~I sn JZO rv /S. V Feet W, r Feet VII. TANK Capacity Total # of Prefab. Site Fiber- Exper. INFORMATION in gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic New Existing Gallons strutted glass App Tanks Tanks Septic Tank or Holding Tank Vt/t-~ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbec'sSignature: (NoSarn MPIrVrFRSWNo.: Business Phone Number: i i11 MIC _ 2- Zz- 1s- -3 ps, Plumber's Ad ess (Street, City, State, Zip Code : IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sam ary Permit Fee ('"`IudesGroundwater ate Issue IssuinZAg t Sig ture ( ps) Approved ❑ Owner Given Initial j~d Surcharge fee) Adverse Determination e2 -r- All X. C NDITIONS9F APPROVAL/ R A~SO~NS R DIS PPROVj►L: SBD-6398 (R. 05/94) - DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS , 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and 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. IL 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 on line A. Complete line B if permit is for tank replacement, rE connection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers i through VII. Tank information. Fill in the capacity of every new/or existing tank, list the total ;gallons, :-Mm ;cr of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Conplete for al'! =ptic, pump/siphon and holding tanks for this system- Check experimental approval only if tanks received experimertr ' product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appro riat _ prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County / Department Use Only. Cr)t!,plete plank ~r~<< ,pecificatio-:s not smaller than 8 1/2 x 11 inches ;-nt~st `)e su I tted to J ie : - unty The plans must nci u~a the foi!owl A) plot,Jlan, drawn to scale or vvith complet u .z_..,i, oc,.J,.,, idirig tank(s), septic ~jtf, ; ent lankbuilding] i2;s, wells, vVc.L:_i rloi!Is/V.~4 , St lakes; pump or siphon tar' E'T' un soil a.-,sorption sv.r,ns, replacerren' system ir< as; 'he lore f the building served; r_. <C _.~i ,lu e (i ~'eva~iUf? reft?i"e Joints; CG''ip E'[t' SyJC: ~Vr p,ir'1 ~t , _o".if Jl`;; dCSe VOIUmr'I elevation di f ferences; friction less, pump performance ( urve; pump m 2': a t _imp rn 3 ' .,rer, D) cross section of t. soil asorptian sys~err~ if r,'1)w°cd by the reu,'~L} , E) soil test date ) sizing information_ GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of r illted pr c<~ which can effect groundwater. The monies collected through these surcharges are used for monitoring groundvvate untam rnvestigations and establishment of standards. ..t~oN .K~NG _RZO SAWMILL LANE APT 5 h AIEW RiCt W10013 W-T 6" 01 SE VLI ME Y9 5 17 T31 N, x.,19 ,o k~T S v0tr ? t`~GE 1867 '¢i~ Sor p-P,WT e 17S I loch 6k W6EKS Zo iZx60 13E'D VV'' r,r^^V yo~.99~ • ,' DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 7969 HUMAN-RELATIONS (ILHR 83.09(1) & Chapter 145) LOC TON`: !SECT i : OWN P/MUNICIPALITY: ILOT NO.:BLK.NO.: SUBDIVISION NAME: 5/j/4 Ott f/4I /T N/R E (or)W ,�` `�6•�c7�6 — COUNTY: �( N � � MAILING AD USE DATES OBSERVATIONS MADE.� '�� NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERGOLA ION TESTS: t�R RS. esidence - New ❑Replace i1` `4'_ ',-j /�— 17 RATING:S='Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptionall EIS UU KS [ 1U GCS f U ES .1u ES 2u .i If Percolation Tests are NOT required IDESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: l '/, Floodplain, indicate Floodplain elevation: W42, �a 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.) B- / 73 c'--J'a //. ,Ye -- ,‘ 6-,7. _ li.10 ..„...e..„ .7.6( _ B ,fir �©"-,�- '1 6-S- , ?,c 74-1 ,e..._ 7461 6,--je A /',. jz-,_ 44( , ',"?....,5 _"3 /�5� f �/ I , B- f PERCOLATION TESTS t TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES t NUMBER t.S AFTER SWELLING INTERVAL-MIN. PERIIOOp1 PERIOD2 PERIOD 3 PER INCH /' 3 P- ,3 Lit- a.. _ c fo t6 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 land slope. 757 SYSTEM ELEVATION 9 -I 4 . . . l N. 0 e0 t,4 it r e1v 1 yh 41 L r J , A,� ��,, /4,- Z-"/- /aa o r v 8 ee7" )(a S f _ rr �� ,p 3 re 39.e 55 J i . ila -- Y 15-I 30 350 �) I, the undersigned, 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): (TESTS WERE COMPLETED ON: /1"1 ADDRE 7 CERTIFICATION NUMBER PHONE NUMBER(optional): fry A,k C e7 Z—Gi/ sae>/ .3 y 7 CST SIGNATURE: a �..mot., t DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) — OVER —