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HomeMy WebLinkAbout004-1083-20-000S't. Croix County Planning and Zoning Tuesday, June 26, 2007 at 1:05:05 PM Detail Sanitary Information Page t of 1 Computer #: 004-1083-20-000 Sub/Plat: metes & bounds Section: 34 Parcel #: 34.28.15.539A Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1/4 1J4: NW 1/4 SW 1/4 Owner: Rudenick, Otto 49 State Road 128 Spring Valley, WI 54767 State Permit: 4203 Issued: 05/11/1970 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permit: 0 Installed: 05/18/1970 POWTS Detail: Seepage Pit Bedrooms: 2 WI Fund: POWTS Pretreatment: NA Issuerilnspector As Buili Plumber Other Requirements Harold Barber NA Mittlestadt, Howard M Not determined Sicneu ~*f: No Additional Notes Money Owed David Mittlestadt MP#2618 did installation -file $0.00 with other permits Owner: Lamb, Charles 49 State Road 128 Spring Valley, WI 54767 State Permit: 5475 Issued: 07/30/1979 POWTS Dispersal: Non-Pressurized In-ground Permit: Replacement County Permit: 171 Installed: 11/15/1979 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA t~€ates Issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Harold Barber Yes Lechner, Edward used existing septic tank (1000 or 1200?)and $0.00 Harold Barber signed Oif: Yes proposed 2 5'x100' trenches, but as built by Ben Helgeson sowns 18' x 70' bed -? File with 2000 replacement permit Owner: Rode, Stacy 49 State Road 128 Spring Valley, WI 54767 State Permit: 363812 Issued: 04/19/2000 POWTS Dispersal: Mound 24" or more suitable soi Permit: Replacement County Permit: 0 Installed: 06/28/2000 POWTS Detail: NA Bedrooms: 3 WI Fund: No POWTS Pretreatment: NA t' . Issuer/Inspector As Buili Plumber Other Requirements Additional Notes Monev Owed Kevin Grabau >4!1/00 -Not Required Rogers, Mike $0.00 Kevin Grabau Sic~neci ~:)tY: Yes Mainten~nc~ Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 6/28/2003 4/15/2005 04/01/2005 4/15/2008 ~~ , Wisoonsin Depart~oent of Health and Sooial Servlaesr ` Plo. {~'r'7 Division of Health ` PERMIT APPLICATION for / PRIVATE DOMESTIC SEWAGE SYSTEMS ~j A, CTr??v'r:R OF' PROrE~7I'Y TYPE OR USE BLACK INK I3ame y, Zip Code) Address (Street, Cit ~// L1 ~(~cJC_~/~'C'~G l ~J~i~/~/~' ~~j/f' ~ County B. LOCATION of PROPERTY wH;•'RE SYSTEM WILL BE CONSTidJCTEDi ALTERED nR EXTENDED ./ S Check One: /. CITY _ VILLkGE LEGAL DE:'CRIPTIONs ~ ~~ ~:~/ ~L/TOWNSHIP ~~~ ; / ~~ n-~'/~/(~J ~ J.. C. IS LOCAL PEFMIT REQUIREli FOR THIS 4AkuC? ~ YES NO r''•-''3 ~~ / p. . SEPTIC TAPJK CAPACITY /OGc~ Gallons NEW INSTALLATION L~ REPLACEMENT ADDITION MATERIALSs Prefab Concrete ~ Poured in Place Steel Other NLG"~BER OF TANKS TO BE IPISTALLEDs ~~ c1' :- E. TYPE OF OCCUPANCY Cheok Ones One or Two Fami]y Residence 1/ Corteneroial Industrial Other Specify Number of Persons to be Accommodated F. APPLIANCES, ETCs Food blasts Grinder YES v NO Automatic Clothes Washer YES ~-NO Dishwasher YES ti NO Automatic Potato Peeler YES ~_NO Other (Specify) G, EFFLUENT DISPOSAL SYSTEM NEW ~"~ EXTENSION ADDITION REPLACEMENT Tile Size - No.Lin.Feet _Trenoh Width --Depth --iu;vber-of Lines - Seepage Bedt Length -- Width -- Depth ---Tile Size. -No. Lines • °~ Seepage Pitf ;Inside diameter - Liquid Depth ~~" k i.. j PERCOLATION TES T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches 'lizutes Number Inches Thiokness in Inches Since Hole in Hole Interval Second to Ne~ct to -Last `"o a^all 1st Wetted Overni ht in Minutes Last Period Last Peri Period One Inch Example ~, P- 0 36" To Soil 10" Cla 26" 25 es or no 30 1 2 1 2 1 2 6O ,, ., ;_ ~ ~ RECORD DATA FROM MINItNM OF 3 T£S" HOLfS ompute size of absorption area in acooru with H 62.20 Wia. Adninistretive coca. ' SOIL B D R I ti G S -Minima:. 36" Below Pro osed Abso tion S stem oring Total Depth Depth to Ground Water De~h to dedroak _ umber Inohas Observed Estimated Observed Estimated Character of Soil with Thickness la Inches xample - 0 72" 72" Blaok To Soil 12"• Cia 18"• Sand 1°"• Grnv.el 2a" ,. , - - f ~ „ - r RECORD DATA .FROM MI^II:NM OF 3 F.C~eF: i;OLE:S COMPLETE OPHER SIDS i I, the undersigned, hereby oertify tha'; the percolation tests reported on this form xere made by me I or under by supervision in sooard with the prooedures and method speoified in Chapter H 62.20 (3), Wisoonsin Administrative Code, and that the data recorded and location of test holes are oorroat to the bast of my knoxledge and belief. NAME i9 l/ ~TJIEv T~ 7 TITLE i~/f, S~7YF.E~ ,/`~%~~f? F/~'/ !.-'F r ~ i Type or Print) ' REGISTRATION N0. or MASTER PLUMBER ICENSE No. _~'7~:E~S l~ / <~ (</~/ ADDRESS /t" r- ~ ~~!~.~~'_ ~~'%cS'P~ - _~ _ DATE /~CJ'j~ ~~~~ SIGNATUP~ ~~' '~ ~~~ MASTER PLUMBER MAKING APP T ON -- -` .~i`~~ -- - Mp .Signatures G r~~``~ Lioense Numbers ~~ / MP RSN (To be ompleted by Issuing Agent) Date of Application ~ / ~~ Fe• Paid ~ ~ L~ --~--- Fermit Issued (dat ~ ~~/ Permit Number ~~~ ~~ i p ~(~ Agent (name) ~..c-L~''-~~, ~ ~Q~~~~{,~ ~ For: ~,,~/~C/ t ~~ ~~-~ Torn, Village, City, County, eta, (Specify) Notes The applioation oannot be oonsidered for filing until all of the above questions are ansxered and the fee paid. Agents rill for-rard application, the Pee of $10.00 and Copy (b) of the Permit (yellow oopy) to the Division of Health. Checks and money orders should be made payable to tha Division of Health. Do not xrit• in spaoo below ~ FOR DEPARTMENT USE ONLY DATY RECEIVED ~ O ACCEPTED BY RETURNED / (Initials) C} (Date) Sae Corres. FE$ RECsrIVFD `-' VALID. N0. ~~O ~ [ ~ PEF3SIT N0. ~~ Yes or No) REVIEWED BY APPROVED DATE .(Initials) Yes or Nol^ COMMIIJTS: 9 C.,AVY ~, 1 T z~ N:-R. i5w 2 -- • ~ /iy s _ a ~ ~ : o o ~%ff f A/ce L ' ~~_ C V Jtt r a nE.e s/ ,C Ler/e~- Ev¢ ` ~N~ ~ ~ Y a.~ f/ r97s/ p `^^, NN s 9 c••"~ „¢ a ~ 4 i F o ~' /28 oe ysfo / /u/vone y ~/ - cmmi.~ ~° y Th /c 5 - Q; « i wC \ o ` ~ aB 67 ' Bo r7 G/QCa Ba- a. . ar . se h f c 1 Edw°.d L . f%a/ L/a/vorson Co h ~ F~ ~. ~~ ~ ~ ~ ~ ~ v v ~.. ~ , C C N Jhn ~j ~SCwCr's `~ v Pe% ~or~ f/eiman Bernard J /moo C9 .//s/eo rzo Q~~~ n w ~ 0 CS d ~~ ~ , eta/~ l y /96 s . moues e% ohcznser/ ~ R • 9 ~' \ V ~ n ?a99s ~XN efa/ • // rays J R/JS 4L / ~° O ~ 7 `~ oa !/ £R z 4a TCr,~e/son ° ¢ Ald • GUa//2 s ve'cd .D am, Da s •p % Gs ~ n { o ~ fa/ r lobe rf- FJ~ o dd./ 6s. r3 9-~ ~ L.L. T imm. nne n ~. Co ° ~~ ,39e ' o e 4d f/u~hes Jr J % i 94 A/f /es Peferso n Vei n ~ " % "'3' lNan q 3 ar vnc sFMay drub e-~ z..3i ,TeG /ahn ..s.s .°o- s Fed o/,ofi 67j R air. 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E ~ ~~~ Eva. ddn 29 suer 40 T' uehn .go r Fie ~ ~ y v V ~0 /iB • y Ao U P P ~ . u9~ne F ; I:~ennef L 7nw.~dsor/ / 28 fierman /60 ,po6• 6. ~ o U~H ~yf / Mi/ on lean e e ~~ ~ ~ ~iei ~ 9 36 ,.LQISO/7 L ' /60 /4 B M~//e~- G 7 7 • Don Lee F ,~ ao C U yj~ eac Pee c n /3riffor7 ' C!°P/° ~ j 0; ~_ ~ ~ ; / • • _ 40 • Bo r~4o ©/972 rQocEford M ~ /ou6/s., Inc. P/ERCE COUNT i' .. 1 ~_ _ ~ . _ 1 i~i•. S~i~-,. ~~ -- - - - - ,. ERICKSON HARDWARE I VERSON LUMBER COMPANY ~ ' R GENERAL CONTRACTING HAHOWAFE $TORf.$ POLE BUILDING CONTRACTOR GENERAL HARDWARE -TELEVISION -APPLIANCES DEALER IN ALL KINDS OF Sales Backed By Dependable Service BUILDING MATERIAL WOODVILLE, WISCONSIN 54028 PHONE: 698-2471 CALL: 698-2467 WOODVILLE, WIS. 54028 .. ~ S~i CrYOZJr COIItjZl~ Planning ah~ ZOfZlhg Friday, June 16, 2006 at 9:33:16AM Detail Sanitary Information page 1 oft Computer #: 0041083-20-000 Sub/Plat: metes & bounds Section: 34 Parcel #: 34.28.15.539A Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1/41/4: NW 1/4 SW 1/4 Owner: Lamb, Charles 49 State Road 128 Spring Valley, WI 54767 State Permit: 5475 Issued: 07/30/1979 POWTS Dispersal: Non-Pressurized In-ground Permit: Replacement County Permit: 171 Installed: 11/1511979 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Insaector As Built Plumber Other Requirements Additional Notes Monev Owed Harold Barber Yes Lechner, Edward used existing septic tank (1000 or 1200?) and $0.00 Harold Barber Signed Off: Yes proposed 2 5'x100' trenches, b ? as built by Ben Helgeson sowns 18' x 70' bed -. File with 2000 replacement permit Owner: Rode, Stacy 49 State Road 128 Spring Valley, WI 54767 State Permit: .363812 Issued: 04/19/2000 POWTS Dispersal: Mound 24" or more suitable soi Permit: Replacement County Permit: 0 Installed: 06/28/2000 POWTS Detail: NA Bedrooms: 3 WI Fund: No POWTS Pretreatment: NA Notes Issuer/Insaector As Built Plumber Other Reouirements Additional Notes Monev Owed Kevin Grabau >4/1/00 -Not Required Rogers, Mike $0.00 Kevin Grabau Signed Off: Yes Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 6/28/2003 4/15/2005 04/01/2005 4/15/2008 a Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safet)~ and Buildings Division INSPECTION REPORT 4GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ^ City ^ Village ^ awn of: Rode Stac Cady Township CST BM Elev.:. Insp. BM Elev.: BM Description: Jl ~~ ~ ~Crs~ ~ ~~~-- TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~lt ~~ ~ Dosing ~l~toD Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic >rU ~ ~,~-- ~S ~ NA Dosing ~ 5~ C`S~ ~ T NA Aeration NA Holding PUMP /SIPHON INFORMATION ~~ ~S ~o Manufacturer L Demand Model Number sue} ~33 2~ GPM T Lift ~~ °~°~ Lriction p,~~j System ~,5 TDH fit, •3 Ft Forcemain Length 5 ~ Dia. z " Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No.: 363812 State Plan ID No.: -CR.~Mrs fD# : 30/9 Parcel Tax No.: 004-1083-20-000 STATION BS HI FS ELEV. Benchmark 3-Lo (03. Zo ~ , a ~ Alt. BM ~ (, o c~3,~p' Bldg. Sewer ~l ~ q~,~.p' St/Ht Inlet 123(0 .S`f~ St/ Ht Outlet - -----~ Dt Inlet Dt Bottom ~ ~ , ~ .dL,a - ~/o.Z ~ . `~(~ Header /Man. z_~S' lcA S r Dist. Pipe 2 ~9 Ie0•~F~ Bot. System ~~ ~ 9•~8 Final Grade St cover (Q N R ~. 3 ' BfB-/ BENCH Width i Length / No. f T nches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N ( DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O n ~ CHAMBER Model Number: System: ~K.~- >zoo 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 ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: DSO/2~/~ Inspection #2: -~---f-- Location: 49 State Road 128 Sp ~, Valley, WI 54767 (NW 1/4 SW 1/4 34 T2,,8~ R15W) - 34.28.15.539A 1.) Alt BM Description = ~? ~ ~°~'~~ r ~ g~ 2.) Bldg sewer length = ~ ~S ~~,~p~~~ -amount of cover = ~ `f z" 5~ t~vel o.~' ~ j ~ "° ~- ~~.C. ~//S . 3.) contour = 9~,~,p~CS(~-a~ ~{. go a# T . 10~.20~ r ~ w o2Q. ~ s ~ t'~Gc~t~!''~~lW_~ I~u.oe_-- v5 , y t.~ ~,.ev^~ -C'~ g ~ ~ Wi ~~ • 5, ~~ Mn,4u.,,.QY- to r'(,( ~~ t$~ ~ Chit( rnsal ror,~c-~y,` W-~ "~`~' ~ o' ~22` ~~'~I PI~ revision r' equaled? ^ Yes ~ No Us other sid for additional i o~mation. ~ 2'~ ~ ~ ' ~ / SB~-6710 .3/97 to Insp dor's Signature a No> % 6 ) CA S`r~`(~ ll.r~ ~'t !/~ " '_ ~ e~ p.~.IM,{~ Q~2/S~ p r-ta1.1'~ C~t~`".'r~q WiV'G.~Ss1, ~~i~consin ' Department of Commerce SANITARY PERMIT In accord with Comm 83.05, • Attach complete plans (to the county copy only) for the ~. • than 81/2 x 11 inches in size. • See reverse side for instructions for completing this appl Personal information you provide may be used for,secondary purposes [Privacy Law, s. 15.04 (1) (m)]. ~~ Safety and Buildings Division LION 201 W. Washington Avenue °~,; P O Box 7302 ~~ °`,~ Madison, WI 53707-7302 ~~ n pag~r~t tes 1T ~F~ ~,~ ~~t. G~~~ l eSanitary Permit Number _~ 363 ~ y ~eck if revision to previous application rfe Plan LD. Numbw~ ~..fS in ~. 30801 Property Owner Name ~ Property L ~' ~! Tag N R E( `~ f! L , , or 3 Property Ow is Mailing Addr ss L `"` ~~ Block Nu /1 City, State Zip Code Phone Number Subdivisi N r SM Number . TY E F ILDING: (check one) ^ State Owned ^ Ity Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms ~ Town OF ~ /yw /a ~ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) po'~-~oaz -4ti 1 ^ Apartment /Condo O ~ - O$3 - 20 5 3~ Iq' 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 ,~ ~S ~ c 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory g~ .~~ ' 13 ^ Other: specify IV. TYPE OF PERMIT: ( ck only one box o e A. Check ox online B, if applicable) A) 1.~~~ ~ 2. (Replacement 3. ^ Replacement of 4_ ^ Reconnection of 5. ^ Repair of an ~ s ____System____ _______TankOnly_______ _______ 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 ^ Seepage Bed 21 @~-Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 13 Pi S 22 ^ In-Ground Pressure ,C~ ~ ~ ~ 42 ^ Pit Privy l~ X ~~ ~ 43 V l P i ^ eepage t ~ t r au t vy ^ 14 ^ System-In-Fill q~j ~ T~ ~, VI. ABSORPTION STEM INF~AATION:~ ~ Z, 7. Gallons Per Day 2. Absorp Area 3. Absorp. Area 4. L ing ate 5. Pert. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Y~ O ~ 3 ~~ Feet Feet VII. TANK Ca aat a INFORMATION in ltos g Total Gallons # of Tanks Manufacturer s Name Prefab. concrete Site Con- Steel Fiber- glass Plastic Exper. App New Existin strutted Tanks Tanks Septic Tank or Holding Tank ^ ^ ^ ^ ^ 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) Plumber's Signa re: ( MP/MPRSW No.: Business Phone Number: tier's Addresf•(Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE O ^ Disapproved [~jApproved ^ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / RE ~~Slt~~ge~~ ~ C~ itary Permit Fee pncludesGrourviwater Surcharge Fee) J~• Z~-r ~ DISAPPROVAL: Agent Signature (No Stamps). _ ~ n. SBD-6398 (R. 4/99) ~ J DISTRIBOTION: Original to County, One copy Ta: Safety & Buildings Division, Owner, Plumber 1. A sanitary permit is valid for two (2) years. INSTRUCTIONS M 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 tanks}must be pumped by a licensed pumper'vvhenever 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, 608-266-3151. - ~ ~ ~ - - - To be complete and accurate this sanitary permit application must include: I. Property owner's~pam~ 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, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. V111. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number.. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. ~ n ruc3e?'the follows sp A ficlot Ian d awanlto scale or with com Mete dirriensions, lltocation of hold ny t nk(s), se m Cst g~ ) p p p 9 p 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 absorption system if required by the county; F) soil test data ors a t~15 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (#eesj-for a riumber~of-regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. MAR-24-00 1.8:52 AM WILI7WOOL! ~~ ~, ~{ ~ ~ ~, ,~. t rl~~ :c35 14rE. P.~1 5 ~~~'`'.I~-1C.--~ ~r`~.~~-~ x,11 ~4'lt~~ ~,.~ti ~. ,~ .~ s~ cy! J . ~~~3.~ _._...~ .~ ~ ~. ~p~a~ r~ _..~ ?~ r ~- __...-........~ r.1-~ ._ ~, ~~ ~~. ~~~~1t~ - _ -`r ~..:. l ~ { 4.. + ~ ~u- r-~ ~~ .~..~ ~ S L ? ~~ ~~ ~.t ~~'Ir~. t~..~ t~~,Ni t_~~l t~ ~~ G ~ ~ S ~ ~ N 6i J~Cus'~h" -~ t ~~ ~ ~scnns~n ' Department of Commerce Safety ana rsuuamys PO BOX 7162 MADISON WI 53707-7162 TDD #: (608) 264-8777 www. commerce. state.wi. us Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary April 11, 2000 CUST ID No.225094 MICHAEL P ROGERS N4563 320TH ST MENOMONIE WI 54751 ATT:~': POWTS INSPECTOR ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/11/2002 SITE: Site ID: 189636 ST CROIX County, Town of CADY NW1/4, SW1/4, S34, T28N, R14W STACY RODE; 49 STATE RD 128, SPRING VALLEY 54767 FOR: Description: REPLACEMENT MOUND DWELLING 450 GPD Object Type: POWT System Regulated Object ID No.: 656690 Iden ' Transacts ID No. 308019 Site ID N Please refer to both identification numbers, above, in all correspondence with the agency. The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: • Location of the well or the proposed well shall comply with Comm 83.. • A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sin ely, c -~, JAMES B QUINLAN , POWTS PLAN REVIEWER Integrated Services (608)266-3937, JQUINLAN@COMMERCE. STATE. WI.US DATE RECEIVED 04/06/2000 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 BALANCE DUE $ 0.00 WiSMART code: 7633 cc: STACY RODE - ~ isconsin Department of Commerce Sarety ano tiuuainys PO BOX 7162 MADISON WI 53707-7162 TDD #: (608) 264-8777 www. commerce.state.wi. us Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary April 11, 2000 CUST ID No.225094 MICHAEL P ROGERS N4563 320TH ST MENOMONIE WI 54751 ATTN: POWTS INSPECTOR ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/11/2002 SITE: Site ID: 189636 ST CROIX County, Town of CADY NW1/4, SW1/4, 534, T28N, R14W STACY RODE; 49 STATE RD 128, SPRING VALLEY 54767 FOR: Description: REPLACEMENT MOUND DWELLING 450 GPD Object Type: POWT System Regulated Object ID No.: 656690 Identification Numbers Transaction ID No. 308019 Site ID No. 189636 Please refer to both identification numbers, above, in all correspondence with the agency. The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: • Location of the well or the proposed well shall comply with Comm 83.. • A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sin ely, c ,~ JAMES B QUINLAN , POWTS PLAN REVIEWER Integrated Services (608)266-3937, JQUINLAN@COMMERCE.STATE. WI.US DATE RECEIVED FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 BALANCE DUE $ 0.00 WiSMART code: 7633 cc: STACY RODE Stacy Rode -Mound Transaction # Location: NW 1/4, SW 1/4, Sec. 34, T 28 N, R 14 W Town: Cady County: St. Croix Date: Apri13, 2000 Owner: Stacy Rode Address: 49 State Road 128 Spring Valley, WI 54767 Plumber: Mike Rogers ~ - Signature: License # MP 225094 Attachments: 6748-Plan Review Application SBD 8330 page 1: cover 2: calculations 3: plot plan 4: system cross section 5: plan view, lateral detail 6: pump tank exit detail 7: pump curve P•®•~$..®~~ 1 C~~ dig .,~~ .. Or ~0`r~ Ull.D1N~S E ENT pEPAR~MSAFETY A~~~ tl N1S~aN~ ~ ~~ S ~ p~.ESP~NV~N~~ E~ ~ REc~~~~D s APR 4 ?400 AF~y,& e~D~S D1u page 1 of 7 System Calculations 3 One family residence Loading rate ~,3 3 Depth to ground water ~~ 2 b ~~ Depth to bedrock Cross slope Force main length Manifold/header length ~ ~ `~ `~ Drainback Lateral length ~ @ ~ °•O Lateral elevation ~ 4"`~ ~ Lateral hole size ~4 in @ (~o.~ ~ holes/lateral, ` ~ `~ ~~ b Lateral volume Total lateral discharge rate 2Z•2 3 ~~'~~ Elevation difference Friction loss °`~ } Total dynamic head ~~`4 2 2 ~ 1 g gpm Pump/si~on @ Go "•`°`_'S Manufacturer , Dose volume ~ ~° `~ Lift/si`~on tank ~~~~ ~~ ~'~°•~+~'~ tc~,r~o'~av Septic tank ~~ , ~`4' Measurement pump on & of f Height alarm from tank bottom ~~~~ ~~~ ~ Reserve capacity calcs bedrooms gallons/sq ft per day in in ft of ~- in ft of '~ in gallons ft of ~ in ft (bottom of pipe) in ( ~•O ft) spacing holes total gallons gpm @ Z•S ft head ft i f t @ ~" ~ gpm ft ft of head Model # 3`8-1 - L?~° gallons ~~~ gallons ~~ gallons in in gallons page ~' of ~ S I OIQ. \~ p~,e ~ `LOT ,~\aK ~~ wS1i~ Z. ~{ L ~`~ ~,. ~ a}oti~ dV~`O~ 1~~~ C.s~.. ~O~,r LI o\.q~ ~-M "--'-- 1 ~~,' ---- Rj,ti o ~ ~ O~ ~i N ~Olka~ ~~ tl ~.. h •~ ~ 0. a,~ 1` 1 1 o L o ~{p c .tea GM Z'tt'k~ µ.~1 o-cly !vy'b ~-o~~.o ~~ 30• ~}" SQ,.~:~ S%1(t (1 f0 M. y~ ~A,4` ~ ~ Q(S ~ ~ ; 1 w~~+. V1n,~ S O.ar V i ~. Q 4 / a ~, ~ f ~.~a ~ woa W.w. e U ~,..+~ a ~.a..o L}" P V C .~ `~ }iw~ t ~. Q„~OMapN ~°~`~ {{~~ (~R,pi~/ O~,tS'O11 `r~ gµ~~t+r1~. (! t okU,U(1~1~ + twl~cf v,. UOG».+ wf. `~c ~~ ~~qr -~- 3 t.,. ~+ 1 11-~•~e ~..~ lam= ~ w~ ~ ~ '~' ~4~.4~ S l~ b .1'3 ~~ ~"Swbso:~ - ~- ~3~. ~~oo.c~ W ~ W 2(\V~~ O ~w T \ ~q q f1,T N ~+ \ ~~ rr` ~ C~ 0~0 .V\i~ ~Xv iw ~O _ -p ~n, ~: \ : ~- 0 0.0.x. ~ a~ ~~ o l , q 1Dne.\t~ 02 lv o ~s~o s~.~~a~~ ol~\~.~. 3 ~~ ~ { .. N • •• • Y 1 ~tr '~N~ ~r ~`~ s S of ~ Q.. r~ ~~ a q.a ((~~ ~ ~• QX cv . c~ct,4. „ .• '~Z~~'~z w•-:4..52; ~,``.~A (~ 4 Ott R~~ ~-- ~d.`Cw 2u j~ 1r o~-~ ~a t-d( O'b ~ ~ p 1 ~ -I \ ~ 4.~e o ~ t 1 ... ta. ~-K c ~ ~+\w i O 1 / ~ ~ 3 ~ ~ ~ ~~ t3tr-~ b, ~ ~ o,p t ~1 1 1 1 w.aSt b s.+~co:, S~wA 1 1 + 0.v ~~ Q• g . ~- "T L a 2 N o~~; ~ e~1~. ~..Sl r i ~.~, 4- o ~ ~- ~~ ~~ V ; .....,. --~ .o ~. ~' `~. o `~-- zi, g \o,~, t o. Z' ---? 10.1 ` ~ `t 5,o ~~s ~~ l o \ C X: `i L s p~ ~.s,` Q,~,O.~, !^0 v ~..: V' 1 t:_~ QJIr i+~ t`~` ~+ ..v ~C.~.., s~.n, : v 4.C,. To T : _ .Sl (~/y~~\, p : ~',` C V .L u. ~P\ o ~o" s a~1. v .L l'+ o.. .a. a.` l L ~,. ~/J o~ o ~-. o i ~r • c.~ ~ ~ V ` l ( ~~ ~^ \ iV o`4~: ~ r-} 4~r .~ ~ ~r wr.:.w~ S Z . ~ , ~ r o w. O.~ o i Ir o~ K 1. i i ...' i_.L i-.. ~:11 I f I I i _. __ ~YC.t.~.~,~,~~1 i ~ _. _ ~.. .. j ~ - ', - -- - , , .~ --- . I . ~o,~ J.- ~ ,~ ~ ~ got ~ ~-~ ~~ ~_ (~ ~U rn s o~ ~ _ U~ .~ . ~ ~, r"~„"c ..I. P1PG 3~ Rp NpISSuRBED SOIL,,. claw' MIN. /~i1iLLT /OPPQO~rsQ ;K>rT 3Dr~S V PIK - Ktr ECTI Otli ~e~ , ~~.~s~ ~~v. ~- X 1 't" 1/ GL.. T '~ . I LOCKING~COVRR '- twICK p~~GOy~~CT- 4" C.I. IM~/<b11Oq~M~Mi 24" I.D. N1A-i110LE A \ 4 c D a'/T 2(O•b" BAFFLES ~,~ ~- ON ( q 4 `' . N // r o (/. ~ a I",/~1N wESTWERPaouF JUNCTION &aoc "wcc.v 1 NO:~ $.1 CvaCREt'E t' 6~oCK ~I' • d ~ '~' ,~,,Q / i 12~ riii.i/ i 4 C.t. YENT ~` ~C.z. 3' o~ro NKG~ST~, GavuKc SEPTIC f E I G TI 005E ~ ~ ~ ~ ~ TA-JKS MAIJUFACTU0.CR: ~ ~~ ~""`~ IJUM6ER OF DOSES: • PER DAy TAAJK 512C: ~~D - 19Y ~ GALLOIJS ,DOSE VOLUME ~ ~~ ALARM hlM1UFACTLIIR,CR' S ~ L14.~ `~ IIJCLUOI/JG OAGK/LOW: GALLOlJS MOOCL 1JUl+R~CR: 1 °~ ~' `'`~ • t WLl.0U5 CAPACITIES: A = ~~ ~' IAiCHCS OR ~~ SWITCH Ty/L: ~~~"""' ~~ L g c ~` IIJCMES OR ~T GALLOuS ~ cM. ~ g} ~ , (O ~ ~ (~ PUMP MAAJUFAGTURCR: - ~ ~ G a IAICHES OR GALLO-JS MODEL IJUMDCR: ~ `' ~ ~ 0~ ~( INCHES OR AO Z GALLO-JS ~ SWITCH TLiPE: V'"t'"'"`' AJOTE: PUl1P AWD ALARM ARC 70 DL MIAIIMUM OISCNARGC RAT ~'~ ~ G-/~ ~ INSTALLED OIJ SEPARATE CIRCUITS '~ VERTICAL DIFFER[IJCC DCTW[[IJ PUM- OFF MIO OISTRIDUTI OIJ PIPC.. __T FEET + MIAIIMUM AIETWORK SUPPLY PRCis;URE .... .. . .. . . Z'~ FCET + ~~ FEET Of FORC[ MAIIJ X I', F%jpp~xFRlCT101J FACTOR. O~ } fEET ~ ? ~ .~,~ ` ~~ = TOTAL Cy1JAMIC NfAp ~s14z- = FEET ~ 1t~ 4 AJTE J ~ ~1 ~ N ~ ~ •~ RI I AL. DIMEIJSIOWR OF TAIJK: LEAJ4TH ;WIDTH -;LIQUID DEPTH ~ia~-~ _6 nF v ~~ , .1 / Pump Specifications LD5 I ~~~ .~/ r ~,1y~ d '/a H P Up to 40 GPM Discharge size 1'/." NPT Solids:'/B" maximum Motor Single phase: 115V Materials of Construction Brass/thermoplastic Features and Benefits •Top suction eliminates impeller clogging. • Corrosion resistant construction. • Float actuated switch. METERS FEET 25 7 c 5 zo a = s cv 15 f 4 a c 3 10 2~ 5 o~ o --- . 0 5 10 15 20 25 30 35 40 U.S.GPM 0 2 4 6 8 10 rtPihr CAPACITY All Models are designed for continuous of 5 25 0 ~ s zo v 5 a is 2 4 0 3 10 2 5 MODEL: 3871 ~~ °p 10 20 30 60 50 U.S (3M 2 4 '6 8 10 12 m~M CAPACITY , P p Specifications Features and Benefits ' ,o and'/~ HP • EP04 impeller- semi-open design p to 60 GPM with pump out vanes to protect Maximum head to 32' mechanical seal. Discharge size 1'/:" NPT • EP05 impeller -enclosed design Solids:'/.' maximum for improved performance. Motor • Rugged glass-filled thermoplastic All motors feature ba{I casing and base design provides bearing construction. superior strength and corrosion Single phase: 115V resistance. Materials of Construction • Cast iron motor housing for Cast iron efficient heat transfer, strength.. Thermoplastic and durability. Stainless steel • Corrosion resistant threaded stainless steel shaft. • Available fu'. automatic and manual operation. • CSA listed models available. ration and feature stainless steel hardware. ~ o ~ ~- Wis ~nsin Department of Commerce ~ ~~S/~O~IL AND SITE EVALUATION Page 1 of 3 ,Division of Safety and Buildings OR'G~~~rd with Comm 83.05, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less than 8'/s x 11 inches in size. Plan must i Count y include, but not l mited to: vertical and horizontal reference point (BM), direction and St. CrOIX percent slope scale or dimemsions north arrow and location and distance to nearest road , , , . APPLICANT INFORMATION - Please print all information. Parcell.D.# 004-1083-20 Personal information you provide may be used for secondary pu rivacy Law, s. 15.04 (1) (m)). ieWesl By Da ' ~_ Z0Q'~ ` Property Owner ~, ~;.. ` ~ ., Property Location Rode, Stacy ~~ ,~ .Govt. Lot NW 1/4 SW 1/4 S 34 T 28 N,R 14 W Property Owner's Mailing Address ~~ ~° ~^~-~~ ~ ~ ~ 49 State Road 128 ,' Lot # Block # -- Subd. N me or CSIu(~ City State Zi 'Codef .~neyumtte}~ ~' S i V ll WI 576 `~ 2 7~~`F - City ^ Village ®Town Nearest d pr ng a ey 7 15-77 -33 Cady wSHw t28 New Construction Residential~ F~r~~ Afi.~edroom~ 5 ^Addition to existing building ~ ~ U , ,~ se: ;^' Replacement ^ l~ilblic or 6bmmercial describe ,' , Code Derived daily flow 750 ~ Recommended design loading rate •5 bed, gpd/ft2 •6 trench, gpolft2 Absorption area required 1500 bed, ftz 1Z~`t~-~renc(i, ftZ Maximum design loading rate •5 bed, gpolft2 •6 trench, gpolft2 Recommended infiltration surface elevation(s) ~ 99.4 ft (as referred to site plan benchmar Additional design /site considerations'nstall 4' x 95' rock bed mound on 98.4 as upslope edge of rock w/ 1' sand fill Parent material loess over till Flood lain elevation, if a licable NA ft S=Suitable for system Conventional Mound 1n-Ground Pressure AT-Grade System in Fill Holding Tank U=Unsuitable for system ^ ®U ®S ^ U ^ S ®U ^ S ®U ^ S ®U ^ S ~ U ~7VIL LIG~7~-RIr11Vlr RCrVRI Boring# 1 Ground elev 98.4 ft Depth to limiting factor 2 Ground elev 97.0 ft Depth to limiting factor 29" Horizon Depth Dominant Color Mottles Texture Structure Consisten Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ~ Trench 1 0-8 7.SYR 3/1 - sil 2 m gr mvfr cs if/m .5 .6 2 8-15 lOYR 5/4 - sil 2 f sbk mvfr cs lm .5 .6 3 15-26 7.SYR 4/4 - sil 3 m sbk mfr cs lm .5 .6 4 2~ 7.SYR 4/4 f2f 7.SYR 5/8 sil 3 m sbk mfr gs lm .5 .6 5 37-42 7.SYR 4!3 c2d 7.SYR 518 sl 2 m sbk mvfr cs - .5 .b 6 42-48 7.SYR 4/4 c 101'R 6/2 s 0 sg ml - - .7 .8 Remarks: occas,unar vy sl roars on peas a-co; comrpon uy st coats on peas ~b-s i- 1 0-4 7.SYR 3/I - sil 2 m gr mvfr cs lf/m .5 .6 2 4-8 7.SYR 3!1 - sil 2 f sbk mvfr cs lm .5 .6 3 8-29 l OYR 4/3 - sil 2 m sbk mvfr cs 1 f .5 .6 4 29- 7.SYR 4/4 f2d lOYR 6/2 sil 3 m sbk mfr - 1 f .5 .6 Remarks: uccaswuai vy sl coats on peas a-ty SST Name (Please Print) Signature: Telephone No. Henry F. Grote ~ 715-665-2681 ertt to or estm a@ 4ddress P O Box 57, Knapp, WI 54749 ~a28/2000 222774 tuber Re1031 PROPERTY OWNER: Rode, stacy SOIL DESCRIPTION REPORT ~ page 2 oP 3 PARCEL LD.# 004-1083-20 Certified Soi esnng 3 Ground elev 98.4 ft Depth to limiting factor 26" Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsistence Boundary Roots GPD/ft' Bed Trench 1 0-6 7.SYR 3/1 - sil 2 m gr mvfr gs lf/m .5 .6 ' 2 6-12 IOYR 5/4 - sil 2 f sbk mvfr cs if .5 .6 3 12-26 7.SYR 4/4 - sil 3 m sbk mvfr cs if .5 .6 4 26- 0 7.SYR 4/4 f2d 1 OYR 6/2 si] 3 m sbk mfr - 1 f .5 .6 ~,,..,,..~,.. . common v s~ coa s on oe s - Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor ~z w:< < W S 1•+ ~ Z~ L~ L ~~ ,mss ~ ~..~ 5,~, a~„ ~~ Lq~.45 C3_;3 ~a ~~ ~ ~'°~ z~'~ ISK Ll o\,q ~-M `--- \ ~~-' ~'~w x .•-- ~`l'k, o ~ ~ ~ ~~ ~~ i3r+ (-oo.o~ ~qq,\~ Ly." 17 V C J~„o `"_~ N ' ~ yJ- ~GAN ~ ~c~oy ~~- O ~~t~~~~ S o.X, lti ~ e...~. ~ ~V~~`~ Sfo 3d~ ~ ~y1 ~ KcG.w6.~. U M~1, ~..o N~..~ _5..~. 34 - z~ • l4 ~ ,~ i ~ ~ o L o ~{p 1 1 ~-~J c`~a„~ (, G,M Z2t~~ S% K (o w. ur,b~~ ~"~ g S.l s iw~v~ Sor.v. ~Q r l. ~ ~/~/ .Z \ Q / ~~~,~\ ~~ ~~~ nn ra...•e ~+-c~ iK Q~V O M T\~ V~ N M 1n,ti\ %w o~+a. ~a1p ~\ol.q~ oe ~• 1V o ~S~O S¢.~ `oae1~ ,~~Ob1Q.wr I(:1U0? ST CR01X COUNT' SEPTIC TAN'rt. MfAIN'T'EN.4NCE AGREEMEluT Ai+ID • OWh'ERSFiIP CERTIFii~`A'FION CORM OwnertBuyer ~ d ~ _~.. Mai3iag Address ~~~,~ ~/a g :Property Address (Verification required fr©m P12tttYirtg ~partincnr fc; nt;w arastructionl J Si/7C 7 CitylState .~tor~~c ~.~-/J~~'~G/~ Parcel rdt;ntii:ica~.ion Number ~"Oo~-l©A3 -ab~ooo jrE_ GAL DESCRIPTION Property Locatiru ~~lW '/~, .L t!4, dec. ~~, TAN-P' I S ,W, Tow: of C Subdivision .~,.. ,,.....___~__~______~._.~, Lot ~ CertiSed Survey Map # `'~• - --____-, Valt,rz:e _ ----~, Page _' Warranty Deed # ~~ ~ ~© ,Volume ,;.~~-.--» Page ~ . ~,~2 ~. Spec house ^ yes ~no Lot lures .c~t:rttifsabit; ~ y~;; C7 no ,~„y~TEM MAIlti'TE111~1,NCE Impmper use and maitztenanceof your septa ~ system w~~uld re.-sit isi ! .~ prert:atuzt f~iltue t+o ba+.dle wastes. Proper maintenance coeaiabc of pumping auk the septic tank every three years of soan.er, if n~~ ~~~;d l=y a lic;easactputnper. What you pu; nto the system caa afi'eot the liu:~ction of the septic tack as a tzt;xtment :~ta~c ica the wa:.te ~!ispoaai sysr.:nJ. 'Ihe property ownec agrees w submit to St. ~'roix :,,acing fJfcar~:zncnt a certii7.at5un t'anxti, :.igr-ed by the c,wner and by a mssterpltttnber, jotuneytnangltunber, restricted plt:tr:ber csr a aceusecl a :rul}er vcrifyiag that {1~ the on-si~o svastewaterdi:;;wsalaystem is in pmper optsrating conditidu andlor (2) after it~::pcetian and pttrrsp+tt {it aecessa<y), the septic tank t:, less than I; 3 foil at° sludge. Uwe, the undet;sigaed have read tha shave requitement, and a,gr::e ro tn~+im,ain t:i~~ private sewa3e d~spos;ti system vs-ith the standards set forth, herein, a 5 set by the Ucpartmeat of ~Qnl1TiCIt;C anti the Dtpan ~er..t of Na±u-al Resources, ~~tate ~f' Wisconsin.. Cartifieatiaa stating that your septic system has been rnaiatained must be ce~mpleted ata.ci rvtt<rzted tot the Sr. c:.'rois: +:;otraztt`, Toai+¢g Office within 30 da f the thraa ilou er..p' tion date. SI A DI+ I:Pl'LICANT DATE OWNER CE l2.TIFICAi~'iON 1(we) certify that alt statctnents on this fatxr. are true ,., rite l~us; t~:'lny 6;ulllj kro~•tec~~e. I (~•ae; azz (arcj ti'.e ownar(s; of the property dscribed abovr, by virtue of a wan asi J~ +feed re .~e~rdcd i<, Itch ,rer of Deeds flfficc. SIG1vA'I'[~12E OF APPLICANT 1 DATE -- ss*ss,~ Arty infotmatian that is mis-repre^~nte~.ima; result .n !~:- sa:r,~;3 t;.: ::xit being revoLet3 b the :Z.nning Ue T,•artment. "~`«#s« «« Iacludo with this appllcAtion: a stamped +~°arra~t}• dct,d ii~ym tuc ~•~gtstGi of Daeeds affic:c a copy of the c.;rtified stuyty map c; rtferw~_ce is trade iII trie waisanry deed rJ88~ JO STATE BAR OF WISCOVSiN FORA 3 - 1982 a~ QUIT CLAII~i DCED OOCUMtNT NO. qui[-claims to ~~Qt C~ i- t i~-a~ ~.. w~ ~ ~ ~' 1 b ~ ,t 5 4?b1 _- the folhwing described real estate in S} • L~o~k ._ County, State of Wisconsin: L Z~r\e. sOJ~h tea, ~- ~~- ~V~~nwZb}'.~ p~- ~-ltic. 1Ja~~v1Q5~ `~N'~~e (\o~•~h~~y O~ fie. (lor~lnvses~~~N -~--~`a~-Pof-l~~lt~--'~t v~C fie. Sw~lnv~es~ `~y, ~xce p~ ~1.1ne. •~v~~n ~ roA ~~ntr e o f j R ~~ ~~ Se~~: otn 3U ~ ?a~ojc. ~ S ~:-c s~ Tn,an sh ~Q a~ , ~vISW-~~ ~0 0.~\~iC`iCP~ nl:vl, I ~K , pFFICE • ST. C~OIX Cn,. WI a~Ctf !ar ~t-0rd OC T U G X998 •oo R`~'~ 4.l.Jaln TNiS S'ACE RESERVED FOR RECOROtNfl DATA NAME AND PFTURN AOORESS S+ctcy L . i2ode. y4 ~\w~,~ fag W= S4~b~ SP+ ,,~ Jal\ey a ~u 2D au~ ~~-i08~-`ad ,- CDy-/U83-3L~ Y• 5 PARCEL IDENTIFICATION NUMBER x This , S homestead property. (is) (is not) p. Dated this ~`•' day of -`~rn~r , A D., 19 ~ V `~ • ` 1 ~ (SEAL) . S~aLy L • ~od~ . Chris ~ . Re~~ i_ _ (S&11) _ --- (SEAL) AUTHENTICATION ACKNOWLEDGMENT Stag of Wisconsin, Signature(s) ss. ~~ ~'~ ~ ~ :;ountyY authenticaced this da•- of , 19 Personally came heforc me this day of • T~f~". ,r19 , the a •e named < < i E~ Z _~ TITLE: MEMBER STATE BAR OF WISCONSIN ~ . ~~"°""~-'--- au[horized by §706.06, Wis. Stars.) to the iaaewr+ bebe,,tl -u'rw executed the foregoing rncrnrmvnt ami ~[(~_n.~rtldYe ,. '~`, . ~ -~~A b; _,. •i ~~.i ~•, ~la:.,g • a: ITHIS INSTP! IMENT WAS DFIAFTED BY ( ~~~,~~' _ ~~l d~ 11 L 1~~ • \ ~C l~f ~i _ t• - Ncxary Public, U. ~' ~:{_' County, Wis. (Signatures may be authenticatca ,,r acknowledged. Both are not My commtss n is perma~Qt. ,.~( ,riot, state expiration date: t - ~ ,,~.a~.) • Narrts of per5on• •~giing in any upacny should ~ * aped or printed bel.~.. rhea signatures. S TA(E nAR OF \YISCONSIN Wisconsn Lttgal 81ar k f~..:n: QUIT CL+t+r DEED ~ Form No. )--1982 Min.ar-w• VY.. y, , ti r f s: «a "~, { .~ "~s f %x' t: ,~y: .. ~''+ : ~ •e .a E~ `:~ w ,~',, r~'r'~ 1 K * ~ y ~ ~ _ :~ ~ g t.~`~ ~ 4' @k" >~, t. _ -'~W FROM T A n f?'91 FAX N0. r~~. /NletoruaN Sehnerrl~!y Mlawticptadals _ V525s)^~ _ VS73~1 flmse er I/4 1/3 FeN Load 8,0 10.0 Mere SLadvd Pole (4 pdc) -- .T~ R.P.11{. ) 550 Phelso 0 1 r volt a 11 S N"A: 6H _ Ierecml)teat e 1~0°F Am6ieer IR1110 dt Qass A pistlt~ a SMO 1-1/1" rover frlde N 1 /,~" trap 30 Ars. Pewet Lard 1818, SJf1M, f 0~ ssd. (~/Q~ eptlaeal) 11 Ml 9 8 Y8 I 4 ID T~ ,_ q p - C~pacdY, IC 6iy/, d i0 9p 40 sp d0 r--.._..~~ _. tllur/r~d Ofl ?.` ZA Ss n metesltr 7 z d 6 I m 1Z Dimensional pater 23 ~ ~ P "^ ... may,. ~ ---F'1/tr *Ut. .-- • - s ~ •Vr-NI'r Details Pump ChQracteristics Performance Data Mat®rialis of Canslfirucfeen pMeltle Sterol plots Cast kon Sfr~ ~~ 111oclridoSl ~f ~ Swl Faces; Crstieo/CeranUt Seel Iody: Aaodi;w) 5twl Sprllt~ S)aMkes Sled sepowr. swell 9t ilwrme le~rie U Beale Oran Uoe Sleeve [aver S' M Rew Hap Bwri Str+deer/pass Plesfic Fasteuars Siyi"lcss Steel Jun. 29 2000 08:58AM P1 -- - - I l: I t \4•N' NN'~j' ,,.~~ ,n ~ _ ~ ~ ~ ~a~aw~ i ~ __l~°'_~ 1~ io w~r~t~.vs on i CISCHNICaF ..Ccti~r~~~' ~ l i svr '~ .~° A.! direns!an5 Mr irt~hns, M"r'ic to Inrarnv:igitiv: uae..ompgren: OlRbrlstgns lrlay varyt 1/B Incn. Dirr~enai,nal data nr.: for ,:nnecn,::~igri uuronse: unieas cEr:lflee. ar»dnolocrs ana M'B1GMS are sppreldmam. 9n/aFi Ir,~el adiust«ae, N/a r"Ean~e ItK floli' .u mate rsvi9!orls to Ou! pralucl sM tfia/ sprelAratlgne wimt:ut no6cv. ~4 1 PYY N dromuliG', A1hku+d. Ohio. Adt Ri t5 ROioN6d. H'1rD R O M AT 1 C ~ - Teur Aulhorixpd tomi D;ski6uia~ - Pertteir Putniip Group I sd1) Berney Road D.shiaxJ, phis 4.4805 Tel: 4f ~}-at39,3G~t2 fax: 4? 9.281-4087 v+.~+:hydromalic.mm ISO ~1 Certifred ,_ . Item dr; W02-8390 1 W89 6M ~IiTTJ 17 TrrJJnc TCV r•r 'r '1nL Ten A" ~ err .. .... ~. .,e. .-_ ...~ ._.. ~nnY T.28N-R.15W. 23, ~ ~ ~~ SEEH PAGE 37 ~ a R ~~~/ ,Don s l• ~ ab't. . • Lester //aney F Hnn He/cn • 77L ' °,~®. r ~ C/ ff'..F, A/•ce y b ~ • O'rsea a /rg s l~- C 0 C ,6enystoa / u Lee S W/fc ~ ~~ a!ah L d y titl U 0 w ~ h Bo BO Pau/.' ie Bo .Being d J hN /r¢ C 0 0 y yCj~ 'atl ~ C r. ~ha~.sen rzo 0 tlF l 0 .Tohn `-7 cSch~fts ~ e~mairc/ os. r ~ H /i ~ Haio/d i F v, U\ ~ y ~ l V U~ ~ aSauer• ''~~1 ~ Kuese% ~ -> >ra NN Ha/vo won Q~ll '0~2~ dj\tlj ,~ /99.95 eyzx/ ~u y /9G.s eto/ z4.o r1O AL DO /zo ,^7~ p`no 3`W /ZQ U{~ N • hn //7 //FP ,Pobcnf'.9 /!¢ns ~r Qsca ~' hn Eve/ n ..Dan ~C`C 46 ~~ ~'r v9\ n F pn de Hughes T. 7bcko/se te- K./- F y -D¢"/``' W \ s4 40 /sYs i~C a'ah/ WR//es /e/-d G. L. 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U y ZS y X Vj Anderson ~ ~0 .0 ~ C /vo ~ Gj ~j qo y\ l,0 l~ 0 d 0 0 00~ • ti N ro om~y .C~o i~o• aifa.- • My_y OsH °j~ boob tlaLO 0\'~ Ldp ~~ N 2 N •. b c G•F.e. w Y' `~ ~ C \ E s a.-.n c, ~C \ \ tl ll' 0 ~~ n J W N ~' V \~4 /so Ment- C-; Cy ~ C tl 0 l\ 0 .C~ox¢// F or a FCjenev e/e ~~ V A5 ~V~ ~~ ~Q'[ y v t 'v~so " z Bo 3a~p` w~ \~1 b v e~ ~,C a P ~ ~J 111. Bo %BSOead ,tiir/e/- ~ . A. 0_ 40 o yV~ .l A 4/ ~~ rz.s CAOY @ Ch 2 9u /mcrY Lestc~ f /e9 • R+B ~ e~ F 7o tlJ 0 > • ~ ~ "s /yar"/in E lrOn Oi'/o~ Oro 2 W Ch st hr ro ~~ N ar'o.@ / u y~ o Ae ,.7. • rge/em/y i/e.- • F ~r s cn FiM i%ri /e DSO ~%/ ~ U u, C p z9nego ~C /Pobe,-t g /6'0 • 0 ri//ci 7'•" Bo Bo 70 4 Rio C d N a Bo p0 £ 't9 1' /°¢}rr Cr4 0~ ~ W¢/te epP ; 0 • 1Jo>is£ h'e E F h Pi~r(~ston \~0 U Faber- sB.3i • SJ¢n F • tTu~ "on .P. ~ar%e~e • Ec/9e~e ~ 0 0 I~ h Vl0 zzo. 7s ° rUeisri> ei' T>Txm //i/7 boe. Corulonc ~~ ~V 0 ' + • .yin o a'ma .V b bo /A G~ V 0 0` e~/ rsg.7 go `9BO • Moggo ~~ N -/7 1 b 9 z/o Leono ~d• Kr fh' enc ~ ~ />a~ya~et /os .Dona/d `~ A~e/;s E/`~ qe~n h`h e - v ly Q' O/son /Y wy, 0 L Hassan w U ~u~e son ~~'~ >` mm Tud e ~n x V Bo ~~"9 ¢o~ 90 ~10 Bo /rte ~o C~\0 Bo tl~~ v~tl T7B Ba~~ 1r)lJ • PJ . fJer rxa~d F rf¢ l l\ Edna ~a"~es £ ~~h6 y tl ~0 Me/-tan v ~ y 0 LQ /ern o D ~ en hri/e K ll /iry:,,¢ W~ ~~F guar-a.s ~ o~ Tr~,.nefa/ B ~ 9 t/ar{i`roton fir~mrof n tltl Chi'%sfoph- ~ S Lamb • Il0 Bo s ~V yzs e s hro/e' vd V ~ Bo C)J~0 ~ Bo OAK R/ Of 9c • ORT RO. 7 • _ -- - /°.n OAK R/OCE WT f O. T ea/off ~ ..DP¢n >= .2o dne vo 9o Ho ve/7 40 ~rcha/rY. 4 A n -`1 an/'c `,gFTica/f Neubauer /~~y H~.,9h S/+2/7/Cy CTGLCObS • 7 /~m~ • ~ Ba // B° ~L. E.~ 77 go h'ampl-o~ a v q fE/e¢ncT /¢o l~. 0 O/son James•F Thomas L.. ~ n ~ n R. st~ M NOe o~es '~ ~o~D f zoB dlJ James F v~ n.a Mo/denhau- z.3ss T~ m / b F~ ~i ~1l /so Drk.e 9' e~ ~/ ~ /yar'cott Jja.hms No/crud • Bo 9o Bo Bo Sfr-i 9e.- ~ ao ~ _ Ot ~ C7o/-dor' -Pas a/e Ke neth Jo n /oo Ho/re- //6x_+17 ~tl y yar• ~iyawc/ .Pa¢- fChannic of 9 W/Y/ an V 17x H E zoo s6 d scfi //G T mm : 69. e/ h U \~ 4 C y 79 a1r+' ,B~ahmc,' ~ 0 0 ~ c e~yGe3 ~• .ea" Ba ~ ~ C ~ lC~ tlOn ves ~7o~a/d ~ Leon- 1 0 G tl~ Bo M ~ .e u Zi ~ 1 I :/iaye f 11 ~~/ /zo . Na~/ y E/3¢beth Tmm `'~ 'gyp Q ^~ °j ~l5 Kado ~y tt~ 1 P~ 9 ~ 0 a-o (~ FIJo a Lee y ~ ~} zoo.88 a// ~ son, iJ~ahme/' ,jA pl v y R _ • t A9~;~s !../i/iia.m ~ +- • W ~ ' % asst L/o~Y Nei . F o 9~ -~ l Z'~\ U C HB'/en r/e.xt- A3r'ahmcr- w .Y ~` 1\ m ~ Yaerx.- B S Kor/ea aT Lit C o Maw aie/" ~i' l C~ (- ~9 \ e/ Cva S .f. 0 y 0 //o~frran /and 78.32 `C ~T1)0 C~ 0 V p00 l' 0~4~ Q1 ap fo 40 W f3 0l o Har/c -/ : CCl3 ° vjj-U~ cf a0 h~ '~~.0 zx /QS >; NN o U \ zoo `y ch. P '~ `~ ~0 t tl y 0 j ~ U w Cf ina/scrs 2 as. /5 `~ `I Ur. l' ~~ /46 ~ ahmci J you .:1 n 0 y tl l l l \ l ~ A cSchulf~ .Do 3 r ~ tlCo •c Li .p ~~T" W6 ~cnz/d L. u 1 _ ~ 77 i~ : n>".r' ~f Bo m• w C y Mateo/ic ,Nan>inao //s s. ~ y PP • AU GALLI /zo ~ E a 29 tlCR~ T so bwp 97/~ ~ ' y //a`ye ofl - F/mu~dson r6a ~ f ~ 0 U0 a~ y Q cs'tephen aTac.E tl F yJ Eqg .Tires ' l.SP r 9 ~ /b o /2e t 9da Beff b q.C U /°ear/ l eSond ce ayP- ~ d ~e ry /ia//ey Ken. ~~ /f ghas o%~ Eh~ abL es Don Fe ~ e~ V~~ weed ~~ KaPP%n9 9 .~ RESERVO/~ La s°~ + B/ o ° 4o h ~ B.4s 1 st c~o,:r c'o~nty, wrs ~ /y~g,Qorkfb~d MaP P /s.~Inc„rPe//s79 f°'~ P/ERCE COUNTY P!-ZONE f715) 698-2471 LaPean Implement ®~~ - SONS TOOL INCORPORATED ~` 460 THOMPSON RD. SO.. WOODVlLLE. W/SC. 54028 East Highway 12 -Menomonie, Wisconsin 54751 METAL STAMPINGS -TOOLS & 0/ES PHONE: 715 - 235-7909 SUB ASSEMBLIES a~ • w AS BURT SAr12TARY REPORT OLTIti~ER: , Township , Se .~Tn. N, ~ R /~ W. P.O. ADDRESS: ,Corm ,Wisconsin ~~ . Subdivision Lot~~•, Lot size PLAN tr1Ew !~lnJ s~-: E-fw ~ /~' y Distances & ditner_sions to meet requirements of Sec. H62.20 ,.,,, Dry titell size./! ~ Type of Aggregate 4~r~ ~- {~';~~ Covered with Depth of seepage system ~' .Vent caps. in place r~ , number used ,, + DISCLAIr~R: The inspection of this sys,.em by Pierce County does not imp]y complete coa-nliance with State Administrative Codes. There are other areas that it is ianpossible to inspect at this point of construction. Pierce County assumes no 1i..ability_for system operation. 4 DATED :~„~ f ,.:... PLUMBER ON JOB• LICENSE I~7U2~33~Ti: ~~ ~ ~ . »~ ~-; Z . r San~,~ar~y Penm.i~~ ~ S~a~e SPpx~,c .~ ~~ C ~ , NA~lP ' ° ~~ ~ ~ fownbh~,p S.~. Cna.ix Cau/n.ty ~_ Loca~.ion~~L) --~Sec~~.an ,~'`'~ _ i SPPTIC TANK -- S~.ze~~ga.2.~ans. Nurnben a~ Compa.~.~men~~5~__ D.cb~anee Pnom: Ule~~ ~ ~~. 12~ an gnea~eh ~sQope "'~-~~~ 8u~..~d~.ng~~~. we~.e.and~s ~-~ ~~. fi~.ghwa.ten tip. DISPOSAL SySTPM ,.~~-- f ~ D.is~ance Pram: WeQ.~ S~. ~ 12% an gnea~en ~s.~ope ~~t. . B u.i.~ d Yi g ~ oy ~~. Gle~.~and~ Fz. H~,ghw :den $x. PIPLD DIMPNSTG'NS: __- ... Gl.icl~h a ~ ~nen ch ~ ~ ~~. D ep~h a ~ na efz b e.Zow ~.i.~e ~ ~i.n . Length o~ each .~~.ne , ~ ~~. Depth a~ nacFz avers ~.i.~e ~ .i.n. Numbe~e as .~~,ne~s .3 Depth o~ ~~..Le be~aw gxade~,~! LZ~.n. ~'o~aQ .a..eng~h o~ ~.i.ne~ eZ ~~~~. S.~ape a~ ~'nench_ Z..• .in aen 100 ~4~. ''ll V D~a ranee b e~ure'en .2~.ne~s~~. Deptih ~a b edna eh '"_" ~ x . ~' Ta#a.C ab~sa.~.b~.ioYi anea~~ JV~~2 Depth ~o gn.oundwa~en '"'' ~~. 2 -. Requ~,ned area ~~ T e yp a ~i Caven: Pa 2n a S~naw p PTT DIMENSIONS: Numb en a~ p,i_~~s~(~ nave. around p~.~~s ued - ~,`~~~ REPORT OP INSPirCTION_INDIVIDUAL SFGIAGP SySTPM Ou~s.ide d~.ame ;'e~ To,ta.L ab~sanb .~.a Area njCq u~.n d INSPPCTED BY_ APPR~VPD RPJECTPD DATP ~~C epxh b e.2aw ~.n~e~ ~~. 2 ~~ 14 7~. 147 no z A rn .f~ E H 115 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATIONSW'/a,Nw%a, Section.~Z,T~!~N,R~~~(a[~,W, Township orMe+r+ieipektp ~A~~ Lot No. ,Block No. County ~~` ~~~ tiX u ivision ame. Owner's/W~Ys~s Name: ~~~Q. L.Q~C L+~.~'1 Mailing Address: ~QX ~yD Sp~Z.1NG ~lr~ L.l.~`/' wl~• SU~~6-7 TYPE OF OCCUPANCY:. Residence X No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT-ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS F>>Sh-9 PERCOLATION TESTS ~/S ~eS~'7,9 SOIL MAP SHEET ~ NAME OF SOIL MAP UNIT ~T~N~LT PERCOLATION TESTS. TEST DEPTH CHARACTER OF SOIL HOURS - WATER IN TEST TIME TERVAL DROP IN WATER LEVEL, INCHE RATE NUM- BER INCHES THICKNESS IN INCHES SINCE HOLE 1ST WETTED HOLE AFTE SWELLING IN IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- 1 3~6 s 2.~~ 1Ja ~ Q ~//6 l~/! ~/// Y~l P- Z 3b ZG 1.~0 ~~ 8 s/$ 5/ta ~8 P- ~ 3~ ~6 1Jv ~ n spa ~ ~s y!3 P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, MOTTLING AND DEPTH TO BEDROCK TEXTURE NUMBER INCHES OBSERVED ESTIMATED HIGHEST , IF OBSERVED IN INCHES B- 1 ~ ~3p s t I s S ~ I U2 • 'r y8 80 B- 2 7Z ~o~ a •, r ,~ ~ n ~ B ~ !~ ~~ ~~ •~ p S e ~ _~ ' c~8 ~ ~ I B- B- B- PLAN VIEW (locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ~9Dg ~~~Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. i ,I ..~~ _ __a _.~~ .___ _. .~.. ~C•I~ ~~~-~~-.a_.~ r3 F l ~O ~ -~ ~ ~.U Q ~ p3- ~% 1 •% ~~ ~ S t.~. ~ - s ,~, ~ ~ I ~ ~_ m..,~__ ~~ ~ e ~o .o m ~..~ b ~. ~ ~ ~ 8t ~ ._ .. - I ,~ _ . ~ ..~.. _~~-; '8~3- 9 ` a P _ C ~ ..- ~ ---~ ~ 1 ~1~f .,.~ e. ~ ( ~I_ °h 4 ~ __._ _ _ _ ; __ N ._ .._ r ~ m. ~ ~. .rep __ _ _ ..,n,r,~ •c~e', ~ sc~TM i `. _~3~ , __ ...` ._. _~ E ~ _ ; ~ ~ou~~ _~ ~ _ _~ _ _ _ . ~~ ~ .~ e . _, ~m e~ ~ .~ ~ .~.~~ _ a=m_ .eae _ ~`~.~~1-~ 11~~ 4Q" ~ `' ~`~/~~5~ia~1 1, the undersigend, hereby certify that the soil tests reported on this form were made by me in acxord 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 (printl ~~~, V~ ~ ' 1N `~ G~~I~~ Certification No. ~J7 6 Address ~V'-il? Z ~ L.L$k~l~~'~ 1~U1 . ~v~/ot 1 _- _ Name of installer if known _ Copy A -Local Authority CST Signature ~ ~ _ :.~~ ~~`7.~" P L B 6 7 „ State and County State Permit # Permit Application County Per it # ~ for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION:. '/4 '/4, Section T N, R~,~"(_ (or) W Lot# City _ Subdivision Name, nearest road, lake or landmark Blk# Village _ Township P C. TYPE OF OCCU ANCY: Commercial *Industrial *Other (specify) Variance • / Sin le famil 1~ Du lex No. g y p ~ No. of of Bedrooms Persons S D. TYPE OF APPLIAN~CE~S• Dishwasher YES NO Food Waste Grinder _YESI~VO # of Bathrooms Automatic Washer !/YES NO -0th er (specify) E. SEPTIC TANK CAPACITY Q ~ ga ~o o. of tanks *Holding tank capacity Total I o. of tanks New Installation Addition _ Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ~( 2)1~~ 3) l~~Total Absorb Area Q____7__Q~ _sq. tt. New_ Addition Replacement ~~ *Fill System 7~ ~" ~~ Seepage Trench: No. Lin . Feet ~~Q Width ~ Depth~_Tile Depth ~~ No. of Trenches ~_ Seepage Bed: Length Width Depth Tile Depth No. of Lines ~~r Seepage Pit: Inside diameter-~----Liquid Depth Tile Size Percent slope of land l7 LO Distance from critical slope ~E~Le~. 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 Ce 'fie Soil Tester, ,~ ' t NAME ~ ~r~~ _ ~"e ~ C.S.T. # ~J 7 ~ and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW# 3~®~ Phone # ~~~_~3~ Plumber's Address Do Not Write in Space Below - FOR DEPARTMENT USE ONLY ~ V ~ -3~ ,~p Date of Application - ~ - Fees Paid: State~O ~ 0_ o y l Dat Permit Issued/R~seted (date) ?-~(' -~~_Issuing Agent Nam Inspection Yes~No Valid# Date Recd 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