HomeMy WebLinkAbout026-1029-90-050
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Form Plb 67 ~ Wisconsin State
APPLICATION FOR PERMIT Division of Health i
for
PURCHASE OR INSTALLATION OF A SEPTIC TANK
(Sec. 144,03, Wis. Stats.)
A. OWNER OF PROPERTY Type or use BLACK ink.
Name Address Street, City, Zip Code
A e,,
69. B. e ~~7 LOCATION OF PROPERTY WHERE SEPTIC TANK IS TO B INSTALLED
Check 1. City Mail address 11/C- %y g, 91 County tj~ one: 2. Village W, , A
3 / Zw Ile
Give license number held:
C. INSTALLER Wisconsin Restricted
Licensed Sewer
Plumber Services 17S 461 1~1/" lo ,5-7
Address
LrJ ` %CC C~J 2
D. SPECIFICATIONS OF SEPTIC TANK NEW TANK REPLACEMENT
Size in gallons: Check one
1. _ 500 gal. 4. 1,500 gal. 7. 4,000 gal.
2 . 50 g~ . 5 . 2,100 gal . 8 . 5, 000 gal
3. 000 gal. 6. _ 3,000 gal. 9. Troyer 5,000 gal. give capacity
Materials: 1. Prefab concrete 2. Poured concrete 3. Steel
E. TYPE OF OCCUPANCY
1. _ Single family residence 3. _ Commercial establishment 5. Sher
2. Multiple family residence 4. Industrial establishment
F. APPROXIMATE NUMBER OF PERSONS SERVED DAILY
G. PERCOLATION TEST MADE 1. Yes 2. _ No Date C~(~.•~
By whom
(To be completed by County Cl rk)
Date application is filed and, fee p 'd
Permit issued (date) i
77 < !j~ Permit Number
County, , Clerk
Note: The application cannot be considered for filing until all of the above questions are
answered and the fee paid. County Clerk will forward application, the fee of $1.00,
and Copy b of the Permit (yellow co to t
~ ) he Division of Health Checks and
money orders should be made payable to the Division of Health.
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NAME OF BUSINESS ,Q {
LOCATION 04
rest r h' way city or township count
OWNER Mailing address✓ ...~tah
ARCHITECT OR EN NEER Address
PLUMBER ~7q Address
f
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed:
Existing building New building Addition
if addition to existing building attach detailed memo for each.
Restaurant or dining room . . . . Seating capacity (10 sq.ft./person)
Motel Hotel Cottages Number of unites Regular Housekeeping
2 persons/unit
4 persons/unit TOTAL NUMBNR OF UNITS
Bar or cocktail lounge . . . . . Seating capacity (10 sq.ft./person)
Nursing or retirement home . . . Number of beds
Mobile home park . . . . Number of units - dependent
- nondependent
Service station . . . . . . . . Number of oars served (daily)
School . Number of classrooms Meals served Yes_ NoShowers provided YesNo
O Factory or office building Number of persons (total all shifts)
Residsnos . . . . At~~-k . . Number of bedro ms Other - specify
2. Indicate whether or not the following facilities are connected: Food waste grinder . . . Yes NoJ~'
Dishwasher . . . . . . . Yes No~_
Automatic clothes washer Yes No
3. Fill in the appropriate information for the following as indicated: ~1-
Septic tank capacity planned U v'ti Normal septic tank capacity required •
50% increase for M or Ax Total septic tank capacity required
Percolation test results - ATTACH P=RCOLATION TSST REPORT SHIST
Seepage trench bottom area planned width linear feet depth
Seepage pit planned , outside diameter •S- depth below inlet depth
Seepage trench bottom area required width linear feet
Seepage pit required oZ outside diameter depth below inlet
Signature of person completing form: STATE BOARD OF HEALTH, PLUMBING DIVISION
r~~ P. 0. Box 309, Madison, Wisconsin 53701
Address: Approved:
Date Date
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RL.14" I V- u
t M ~0 1969
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LOCATION 0-x1
street r hihway city or townshi count
I t f~
OWNER Mailing address
ARCHITECT OR ENG NEER Address
s
PLUMBII2-'~i>~ Address
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed:
Existing building New building / Addition
if addition to existing building attach detailed memo for each.
O Restaurant or dining room Seating capacity (10 sq.ft./parson)
O Motel O Hotel O Cottages Number of units; Regular Housekeeping
2 persons/unit
4 persons/unit TOTAL NUMBER OF UNITS
Bar or cocktail lounge . . . . . Seating capacity (10 sq.ft./person)
Nursing or retirement home Number of beds
Mobile home park . . . . . . . . Number of units - dependent
- nondependent
Service station . . . Number of oars served (daily)
School . Number of olaaarooms Meals served Yes_ No~ Showers provided Yes. No
O Factory or office building Number of persons (total all shifts)`
O Residence . . . . . . . . Number of bedrooms
O Other - specify
2. Indicate whether or not the following facilities are connected: Food waste grinder . . . Yes No~
Dishwasher . . . . . Yes .:No-
Automatio clothes washer Yes No y
3. Fill in the appropriate information for the following as indicated: - T ~T
Septic tank capacity planned Normal septic tank ccpaoity required L•~+
50% increase for FWG or AV Total septio tank capacity required
Percolation test results - ATTACH PEFCOLATION TEST REPORT 5HEs?
Seepage trench bottom area planned width Pear feet , depth ,ice
Seepage pit planned L A f`C3o0u side iameter depth below inlet ~l depth
Seepage trenoh bottom aroa required width , linear feet
Soo o it required - side diameter h depth below inlet Signature of pars com leting form: STATE BOARD OF HEALTH, PLUMBING DIVISION
` P. 0. Box 309, Madison, Wisconsin 53701
Address: _r;+_ Approved:
Date Date SEP 11 1969
-
j THL APPR0~7!t. IS QAS,D ON STi1TE PLUMB-
1;45 CODE REQUiRUAENTS ANO DOES NOT
EXEldPT THE INSTALLATION FRONI CITY, VIL-
LAGS TOWNSHIP OR COUNTY REGULATIONS
OR PERMIT REQUIREVdENTS.
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Lab4rand 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 of: State Plan o.:
JEROME FOODS x
CST BM Elev.: Insp. BM Elev.: BM Description: Riehmend 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
Verit
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
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
Forcemain Length Dia. hi Dist. Towel
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 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 xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Richmond.9.30.18W, SE, NE, County Road A
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: '
~I
SANITARY PERMIT APPLICATION
COUNTY
In accord with ILHR 83.05, Wis. Adm. Code 51 G c `
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than -io
8% X 11 inches in size. 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.
PROPERTY OWNER PROPERTY LOCATION
b dS 2 N '/4, S T3 O, N, R ! J?'.&r) W
PROPERTY OWNER'S MAILING ADDRESS LOT # r~#
8a t,t-vX& l G ok6 5 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
+Jrj` ►x,' S Y~~
5- ) 53 7 505
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
_ ❑ State Owned Q VILLAGE : ~I ` yns
I~ Public X1 or 2 Fam. Dwelling-## of bedroom PARCEL TAX NUMBER(S)
'10 ~QWN III. BUILDING USE: (If building type is public, check all that apply) p o7 d
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
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 in line A. Check line B if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Date Issued
i
V. TYPE OF SYSTEM: (Check only one)
No -Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ 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 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) ELEVATION
'r5 6 L43 ' 7 A 4 N A, Feet N Feet
VII. TANK CAPACITY Site
in alions Total of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank l0TlD c
Lift Pump Tank/Si hon Chamber. Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Nap" Print): Plumber's Signat . No Stamps) MO MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
/ 96 0,-- o
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sani Permit Fee (Includes Groundwater ate Issued Issuing Agent Si na
)Approved ❑ownerGivenInitial Surcharge Feel
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the 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 & 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.
It. 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, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
Vt. 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 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.
VIII. 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.
Complete plans and specifications not smaller than 11% 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 absorption 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)
V ev~Ome roods
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT- Page _ of
• Lsbor and Human Relations
Divisiorf of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
.fe-v im • ' yo ~/~,.n ~~Sc GOVT. LOT S'6 1/4 /Ujr 1/4,S 07 T 3 of N,R ~~j E (or W
PROPERTY OWNER':S MAILING ADDRESS. LOT If B# SUBD. NAME OR CSM #
6~r-nrn S I rGZ I E: D~V l Sicy~ J_
CITY, STATE ZIP CODE PHONE NUMBER ❑CITYILLAGE OrOWN NEAREST ROAD
6`~-S-12 (71 SI S'3 -i'.. O S' t e7t avid C
[ ] New Construction Use K. Residential/ Number of bedrooms 3 (J Addition to existing building 'VIY
Replacement [ ] Public or commercial describe -,-J/7
Code derived daily flow `fSZ' gpd Recommended design loading rate o" bed, gpd/ft2 0, & trench, gpd/ft2
Absorption area required c `f 3 bed, ft2 trench, ft2 Maximum design loading rate ? bed, gpolft20: trench, gpd/fit
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
S = Suitable for system 4CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s ste ,®S ❑ U k5 OUT U SS ❑ U as D U J~J S ❑ U ❑ S ;5U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
<rT` r o-~" /oY/z 3~5` ~P / bk czw F C- b
u y Z. q-17•" 16yi'CW J J~ [n,sGK ova tF b.s- b.rr
- Ground 3 1 OVA s?`f C' 4~
elev.
9 to ft. -~~f 10 y,2 S~ ,tits 6( r.~ e'.? C "'y
I
Depth to S' n -~S d ?011R c 6.7 o: o,
limiting
factor
„
Remarks:
Boring # f-
LL'.'mi"4 jalil -
-3 26 U ,0_-qq
+41S
Ground
elev.
co 5
it. 3q- `{1F" 10 ,2 V`f
Depth to
limiting
factor
Remarks: _ &f;A Aes-d CST Name:-Please Prince `r Phone:
Address:. - ,
tl 945 f Sy-. L V1 . 40~
Date: CST Number:
Signature;-e&•'0. A Sr ~J 9 C'
352
nvrug vur.. . - _
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bourxfay Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends
A7 :t
36 A7
Ground 3-r7' b YR s;q ~z'(S
elev.
ft. 1 6Y ~l`f SOS d
Depth to S✓ Yf--3 I o Y/- r(s
limiting
factor
> 7s,
Remarks: 4
Boring #
E:>_;=
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
• - Boring #
y'
MON
Ground
elev.
ft.
Depth to
limiting
j factor
Remarks:
Boring #
i
Ground
elev.
fL
i
..Depth to~-... _ . , .
~ smiting...,,:"
.
-T
factor
F-T-y
Remarks:
SBD-8330(R.05/92)
GO TTFRIED ENVIRONMENTAL
ELI GOTTFRIED
3404 Pleasant St., Suite #2 Altoona WI 54720
(715)833-1400 FAX(715)834-1299
8 September, 1995
Contact: Vern Hanson, Jerome Foods
Address: Barron Supply, 1621 E. Division Street
City: Barron State: WI Zip: 54812
Phone (715)537-9505
Re: Soil evaluation for the purpose of reconnection to existing septic system
Property Location: SE1/4 NE 1/4 S09 T30N R18W, Richmond Township, St. Croix County
Introduction
On 7 September, 1995, a soil evaluation was conducted by me on property located as described
above. The evaluation was made at the request of Mr. Vern Hanson, building supervisor for
Jerome Foods, in order to determine the code compliant status of the existing septic system. It is
the intent of Jerome Foods to rebuild the former 3 bedroom home site (destroyed recently in a
fire). Jerome Foods will use the residence to house a facility supervisor. The existing septic
system consists of a septic tank (size unknown) and a 12 feet x 52 feet drainfield (according to the
soil report of 14 June, 1983).
It is a requirement of the State of Wisconsin, Safety and Buildings Division, that verification of
soils be done prior to reconnection. WAC ILHR 83.055 (3) states in part: "Construction
involving an increase of wastewater load. (a) General. A county, city, village, or town, may not
issue a building permit for construction of any structure connected to a private sewage system
which will increase the wastewater load to an existing private sewage system unless the owner
of the proposed structure:... 2. Provides written documentation verifying that the existing
private sewage system has sufficient size and soil conditions to accommodate the increased
wastewater load."
Note that the evaluation conducted on 7 September, 1995, was to determine the suitability of the
soils to support a conventional type of septic system. At the time of the evaluation, the size of the
existing septic tank was not known. No overt signs of system failure (effluent seepage onto the
ground, effluent backup into the dwelling) were observed.
Evaluation Method
Two soil hand borings and one backhoe pit were evaluated in the immediate vicinity of the
drainfield. As noted in the plot plan, the existing drainfield appears to lay east/west and is
approximately 12 feet by 52 feet. This is based on the previous soil report.
Evaluation of the soils was made by hand boring the soils using a 3-1/4 inch open bucket auger
attached to a chrome-molybdenum extension pole. The soils were reviewed by twisting the auger
into the ground and pulling up soil samples at approximately 6 inch intervals. Soils were
evaluated by hand-texturing the soils and by observation of changes in soil color and the presence
of mottling and/or other indicators of unsuitability for a given type of septic system. One soil
boring was done approximately 15 feet south of the existing vent pipe. A second soil boring was
done downslope of the bed on the west end. The backhoe pit was dug 15 feet north of the vent
pipe.
Background
Information on the age of the septic system and the size of the soil absorption area were inferred
from the soil report. The size of the septic tank is not known.
Number of bedrooms: 3
Tyne of septic system: conventional, in ground system, composed of one septic tank and one
drainfield.
Size of septic system: Based on the soil report of 14 June 1983, the soil absorption area is 12' x
52.
Age of system: Age of the current septic system is unknown although the soil test dates to 14
June 1983.
Field Observations
location of vent pine to soil absorption system: The vent pipe is located approximately 180 feet
northeast of the northeast corner of the former 3 bedroom house (refer to attached plot plan).
height of vent pips) above grade: 16 inches
depth from grade to bottom of drainfield: From grade to the bottom of the vent pipe is 25 inches.
The amount of gravel used below the drainfield is assumed to be 6 inches. Therefore, the bottom
of the system is 31 inches below grade. Soil suitability, therefore, must be determined to 67
inches below grade.
level of effluent in soil absorption system as measured through the vent pine: No effluent was
observed.
general appearance of foliage above and around the soil absorption system: No overt differences
between the foliage over the septic system and the surrounding grasses were observed.
well location: The well is located approximately 10 feet west of the west side of the house
foundation.
2
Results of soil evaluation
backhoe pit (15 feet north of the vent pipe):
0-9" 10YR3/4 sandy loam lmsbk mvfi, dense, aw, If, 9-17" 10YR4/4 loamy sand lmsbk mvfi,
dense, as, If, 17-25" 10YR5/4 coarse sand Osg dl; 25-54" 10YR5/4 medium sand Osg dl; 54-75"
10YR5/4 coarse sand Osg dl.
B1 (15 feet south of the vent pipe):
0-10" 10YR3/3 sandy loam mfi; 10-26" 10YR4/4 loamy sand mvfi; 26-39" 10YR5/4 medium sand
Osg dl; 39-44" 10YR5/4 coarse sand Osg dl; 44-74" 10YR5/4 medium sand Osg dl.
B2 (55' west northwest of vent pipe):
0-13" 10YR3/3 sandy loam mfi; 13-30" 10YR4/4 loamy sand mvfi; 30-39" 10YR5/4 medium sand
Osg dl; 39-48" 10YR5/4 coarse sand Osg dl; 48-78" 10YR5/4 medium sand Osg dl.
suitability: The soils in the immediate vicinity of BHP, B 1, and B2 appear to be suitable for a
Conventional type of septic system.
Discussion
Soils in the immediate vicinity of BHP, B1, B2 appear suitable for a Conventional type of septic
system down to a depth of 75".
The size of the existing septic tank and soil absorption area have not been determined, but may be
undersized by 1995 code.
Disclaimer
Although there were no overt signs of system failure (i.e. ponding on the surface, backup into the
residence), at the time of this evaluation, future system performance cannot be guaranteed due to
such variable factors as water usage, age of the system, system size, and soil type. The sole
purpose of this evaluation was to determine the suitability of the soil three feet below the bottom
of the existing drainfield. No attempt was made to evaluate the functioning of the existing septic
system.
If you have any questions regarding this report, please feel free to contact me at the address
and/or telephone number noted at the top of page 1.
Sincerely yours,
-4,✓,~
Eli M. Gottfried
CSTM,RS
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
La,5or and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
p._ W COUNTY
/1.~ 6e)4 R u ti q:~ 11 s ror
ust include, but PARCEL LD. #
Attach complete site plan on paper not less than eeear;tj
not limited to vertical and horizontal reference porection and scale or
dimensioned, north arrow, and location and distaAPPLICANT INFORMATION-PLEASE PRI B A T'o
REVIEWED BY DATE
PROPERTY OWNER: PRO LOCATION
QO T Sit 1/4 NG 1/4,S T 3 N,RE(or
~~Mc'_o; yu vNrn !ions c ~,.a
PROPERTY OWNER':S MAILING ADDRESS 001 pO LOTS BLOCK # SUBD. NAME OR CSM #
62Y'!7 H I (F, ! ✓rV i S~( v~ r ~o $`$-7
S~V&_ CITY, STATE ZIP CODE PHO TY ) ILLAGE MOWN NEAREST ROAD
nrn ~cJy. s~{f2 (SAS ~(b c~~
13
[ ] New Construction Use Residential ! Number of bedrooms 3 [ ] Addition to existing building y/1
Replacement [ ] Public or commercial describe ;,y,9
Code derived daily flow `fSZ' gpd Recommended design loading rate o bed, gpd/ft2 d £ trench, gpd/ft2
Absorption area required 6q3 bed, ft2 ~'G 3 trench, ft2 Maximum design loading rate bed, gpd/ft20 ~ trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE 7 SYSTEM IN FILL HOLDING TANK
U= Unsuitable for systeffk] B S ❑ U .®S ❑ U ES ❑ U aS ❑ U `~S S❑ U ❑ S'E U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
Z' 17"
Ground 3 ( -25.. jUYA
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Remarks:
Boring #
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CST Name:-Please Print Phone:
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Address:
3'fu'-l L_~-rPS.,' L.`az~,vfl, ~t~=.• S'z/~2.c.
Signature: Date: CST Number:
PROPERTY OWNER vz n.a ids SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
2
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Boring #
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Boring #
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Remarks:
SBD-8330(8.05/92)
GOTTFRIED ENVIRONMENTAL
ELI GOTTFRIED
3404 Pleasant St, Suite #2 Altoona, WI 54720
(715)833-1400 FAX(715)834-1299
8 September, 1995
Contact: Vern Hanson, Jerome Foods
Address: Barron Supply, 1621 E. Division Street
City: Barron State: WI Zip: 54812
Phone (715)537-9505
Re: Soil evaluation for the purpose of reconnection to existing septic system
Property Location: SE1/4 NE 1/4 S09 T3 ON R18W, Richmond Township, St. Croix County
Introduction
On 7 September, 1,995, a soil evaluation was conducted by me on property located as described
above. The evaluation was made at the request of Mr. Vern Hanson, building supervisor for
Jerome Foods, in order to determine the code compliant status of the existing septic system. It is
the intent of Jerome Foods to rebuild the former 3 bedroom home site (destroyed recently in a
fire). Jerome Foods will use the residence to house a facility supervisor. The existing septic
system consists of a septic tank (size unknown) and a 12 feet x 52 feet drainfield (according to the
soil report of 14 June, 1983).
It is a requirement of the State of Wisconsin, Safety and Buildings Division, that verification of
soils be done prior to reconnection. WAC ILHR 83.055 (3) states in part: "Construction
involving an increase of wastewater load. (a) General. A county, city, village, or town, may not
issue a building permit for construction of any structure connected to a private sewage system
which will increase the wastewater load to an existing private sewage system unless the owner
of the proposed structure:... 2. Provides written documentation verifying that the existing
private sewage system has sufficient size and soil conditions to accommodate the increased
wastewater load."
Note that the evaluation conducted on 7 September, 1995, was to determine the suitability of the
soils to support a conventional type of septic system. At the time of the evaluation, the size of the
existing septic tank was not known. No overt signs of system failure (effluent seepage onto the
ground, effluent backup into the dwelling) were observed.
Evaluation Method
Two soil hand borings and one backhoe pit were evaluated in the immediate vicinity of the
drainfield. As noted in the plot plan, the existing drainfield appears to lay east/west and is
approximately 12 feet by 52 feet. This is based on the previous soil report.
Evaluation of the soils was made by hand boring the soils using a 3-1/4 inch open bucket auger
attached to a chrome-molybdenum extension pole. The soils were reviewed by twisting the auger
into the ground and pulling up soil samples at approximately 6 inch intervals. Soils were
evaluated by hand-texturing the soils and by observation of changes in soil color and the presence
of mottling and/or other indicators of unsuitability for a given type of septic system. One soil
boring was done approximately 15 feet south of the existing vent pipe. A second soil boring was
done downslope of the bed on the west end. The backhoe pit was dug 15 feet north of the vent
pipe.
Background
Information on the age of the septic system and the size of the soil absorption area were inferred
from the soil report. The size of the septic tank is not known.
Number of bedrooms: 3
Type of septic stem: conventional, in ground system, composed of one septic tank and one
drainfield.
Size of septic system: Based on the soil report of 14 June 1983, the soil absorption area is 12' x
52'.
Age of system: Age of the current septic system is unknown although the soil test dates to 14
June 1983.
Field Observations
location of vent pipe to soil absorption system: The vent pipe is located approximately 180 feet
northeast of the northeast corner of the former 3 bedroom house (refer to attached plot plan).
height of vent pipe(s) above rg ade: 16 inches
depth from grade to bottom of drainfield: From grade to the bottom of the vent pipe is 25 inches.
The amount of gravel used below the drainfield is assumed to be 6 inches. Therefore, the bottom
of the system is 31 inches below grade. Soil suitability, therefore, must be determined to 67
inches below grade.
level of effluent in soil absorption system as measured through the vent vine: No effluent was
observed.
general appearance of foliage above and around the soil absorption system: No overt differences
between the foliage over the septic system and the surrounding grasses were observed.
well location: The well is located approximately 10 feet west of the west side of the house
foundation.
2
Results of soil evaluation
backhoe pit (15 feet north of the vent pipe):
0-9" l OYR3/4 sandy loam 1 msbk mvfi, dense, aw, If, 9-17" l OYR4/4 loamy sand 1 msbk mvfi,
dense, as, If, 17-25" IOYR5/4 coarse sand Osg dl; 25-54" IOYR5/4 medium sand Osg dl; 54-75"
IOYR5/4 coarse sand Osg dl.
B 1 (15 feet south of the vent pipe):
0-10" 10YR3/3 sandy loam mfi; 10-26" lOYR4/4 loamy sand mvfi; 26-39" IOYR5/4 medium sand
Osg dl; 39-44" IOYR5/4 coarse sand Osg dl; 44-74" IOYR5/4 medium sand Osg dl.
B2 (55' west northwest of vent pipe):
0-13" 10YR3/3 sandy loam mfi; 13-30" 10YR4/4 loamy sand mvfi; 30-39" IOYR5/4 medium sand
Osg dl; 39-48" IOYR5/4 coarse sand Osg dl; 48-78" IOYR5/4 medium sand Osg dl.
suitabilit : The soils in the immediate vicinity of BHP, B 1, and B2 appear to be suitable for a
Conventional type of septic system.
Discussion
Soils in the immediate vicinity of BHP, B 1, B2 appear suitable for a Conventional type of septic
system down to a depth of 75".
The size of the existing septic tank and soil absorption area have not been determined, but may be
undersized by 1995 code.
Disclaimer
Although there were no overt signs of system failure (i.e. ponding on the surface, backup into the
residence), at the time of this evaluation, future system performance cannot be guaranteed due to
such variable factors as water usage, age of the system, system size, and soil type. The sole
purpose of this evaluation was to determine the suitability of the soil three feet below the bottom
of the existing drainfield. No attempt was made to evaluate the functioning of the existing septic
system.
If you have any questions regarding this report, please feel free to contact me at the address
and/or telephone number noted at the top of page 1.
Sincerely yours,
J
"if A~
e.
Eli M. Gottfried
CSTM,RS
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
O WNEWBUYEa Qr swt e acGS e S
MAILING ADDRESS Y. v~E- ` P 1~ ~1~ a l G V c5✓a7~
PROPERTY ADDRESS z
r y(location of septic system) rr- - -
Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section 9 T 3 a N-R -W
TOWN OF RIG h m fty)A ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMER
CERTIFIED SURVEY MAP , 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-
/ L/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. Croat
County Zoning Officer within 30 days of the three year expiration date
SIGNED
DATA -
St Crol\ County Zoning Office
GovCntnlcnt center
1 101 Cann chacl Road
Hudson. W1 54016
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 'j J -e rarr'a 1:5d-W~ y~1`^
Location of property _A6 1/4 N X1/4, Section 9 T,p N-R___Zg W
Township Mailing address jcL w "-'n
Address of site O S 6 ~
Subdivision name Lot no.
Other homes on property? Yes_/~/ No
Previous owner of property
Total size of property Ss~ GCGre~a-s
Total size of parcel 31!r
Date parcel was created n*j
Are all corners and lot lines identifiabl2use) Yes No
Is this property being developed for (spec ? Y es R No
Volume and Page Number R11 as recorded with the egister
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. 4/ a 9-- ) , 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 of App icant Co-Applicant
Date gnature Date of Signature
REGISTERS OFFICE
ST. CGZoiX CO., WIS.
Recd, for RecoA this 12th
day of Nov. _A.D. 19 79
t M.
WARRANTY DEED cat,
Rpbt~ of Dad,
THIS INDENTURE, Made this 17 day of May . 1979,
between DOMAIN INDUSTRIES, INC., a corporation under the laws of
the State of Ohio, party of the first part, and JEROME FAIRBO FARMS,
INC., a corporation under the laws of the State of Minnesota, party
of the second part,
WITNESSETH, That the said party of the first part, in
consideration of the sum of ONE DOLLAR and other valuable considera-
tion, to it in hand paid by the said party of the second part, the
receipt whereof is hereby acknowledged, does hereby Grant, Bargain,
Sell, and Convey unto the said party of the second part, its
successors and assigns, Forever, all the land described in Exhibit
"A" attached hereto and made a part hereof.
TO HAVE AND TO HOLD THE SAME, Together with all the
hereditaments and appurtenances thereunto belonging, or in anywise
appertaining, to the said party of the second part, its successors
and assigns, Forever. And the said DOMAIN INDUSTRIES, INC., party
of the first part, for itself and its successors, does covenant
with the said party of the second part, its successors and assigns,
that it is well seized in fee of the lands and premises aforesaid,
and has good right to sell and convey the same in manner and form
aforesaid, and that the same are free from all incu.mbrances except
as mentioned in said Exhibit A.
And the above bargained and granted lands and premises,
in the quiet and peaceable possession of the said party of the
second part, its successors and assigns, against all persons
lawfully claiming or to claim the whole or any part thereof,
sub;ect to .incurabrances, if any, hereinbefore mentioned, the said
party of the first part will Warrant and Defend.
IN TESTIMONY WHEREOF, the said first party has caused
these presents to be executed in its corporate name by its
President and its Secretartx$Kst::gasxgs2sxalsaxsga~
tsax:~==5Q&5~ the ay and year first above written.
DOMAIN INDUSTRIES, INC.
'11vSFER By
F James H. Buell
k===xtaxsc(mk C Its _ Pre side n~ t
And
H W Dav
Its Secretary
v o t i.: 11 ,..i • .
STATE OF WISCONSIN )
ss.
COUNTY OF ST. CROIX )
The foregoing instrument was acknowledged before me this
17 day of May , 1979, by James H. Buell , the
President , and by H. W. Day , the
Secretary of Domain Industries, Inc., an Ohio
corporation, on behalf of the corporation.
7
v Yf LCM -1INE' A. %I''?KT
W - F' c'x county. Nils.
My Ccin-isLi.:n E'(;;ires G-t. 25. 1931
Cis l 7 A
This instrument was drafted by Tax statements for the real
Charles L. Horn, Jr. property descr4bed in this
1300 Northwestern Bank Building instrument should be sent to:
Minneapolis, Minnesota 55402
Jerome Foods, Inc.
34 North 7th Street
Barron, Wisconsin 54812
State deed tax due hereon $ 729.30 .
-2-
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ST. CROI`{ COUNTY, ;•+ISCO.+SI:1
Research Farm
The Northeast Quarter, the East Half of the Northwest
Quarter, and the South Half, Section 9;
The North Half of the Northeast Quarter and the Northeast
Quarter of the Northwest Quarter, Section 16;
All in Township 30, Range 18.
EXCEPT the tract or parcel of land in the Northeast Quarter
of said Section 9 described in that certain instrument
recorded in Volume "348" at page 585 in the real estate
records of Saint Croix County.
Subject to:
1) A railroad right of way created by an instrument
recorded in Volume "Y" of Deeds, page 593.
2) A railroad right of way created by an instrument
recorded in Volume "38", pane 13.
3) An easement created by an instrument recorded in
Volume "263", page 199.
4) An easement created by an instrument recorded in
Volume "263",page 257.
5) An easement created by an instrument recorded in
Volume "238", page 6.
6) An easement created by an instrument recorded in
Volume "263", page 198.
7) An easement created by an instrument recorded in
Volume "356", page 608.
3) An easement created by an instrument recorded in
Volume "449", page 337.
9) An unrecorded telephone right of :way easement to
St. Croix Telephone Co.;:panv dated April 1q, 13718,
over a stria of land i rod wide in the Northeast
Quarter of the Southeast Quarter and the Southeast
Quarter of the Southwest Quarter of Section 9,
Township 30, Range 18, the centerline of which is
approximately 62 feet East of the centerline of
County Trunk Highway "A".
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DEPART', NT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
L•A6'UR,& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
®CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
fit aeeipnad)
III El Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
JEROME FOODS New Richmond, WI 54017 -15-1.3 0
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:. REF. PT. ELEV.: CST REF. PT. ELEV.:
NW SE, Section 9, T30N-R18W, Richmond Township
Name of Plumber: MPRSIN No.: County: nipry rmit Nu1Mer:
Calvin Powers, Jr. 1563 St. Croix 34807
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPA TANKI L ELM.: BEL TAN T ARN LA LOCKING COVER
i / P ED: PROVIDED:
"?'G, G✓ YES NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT ATL,: IGH NUMBER OF ROAD: PROPER WELL: UILDING: VENT TO FRESH
ALARM: LI AI NLET:
FEE F
❑YES O ❑YES ❑NO NEARESOM ~},rw
DOSING C AMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. MODEL: PUMP/SIPHO ANUFACTURER. WARNINGLABEL JLOCK:NGCOVER
PROVIDED: PROVDED:
❑YES ❑NO P ❑YES ❑NO ❑YES ❑NO.
GALLONS PER CYCLE: PUM L OFERA~ ONAL: 6MffER OF PROPERTY BUILDING. V N TO FR H
(DIFFERENCE BETWEEN LINE AIR INLET:
PUMP ON AND OFF) ❑ ES NO REST
SOIL ABSORPTION SYSTEM. Check the soil moil rat the clepth of plo g L NGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, c truction hall ce until ;#=ORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH'. LEN H: N DISTR. PIPE SPACING: INSID DIA. *PITS. LIOUIO
BED/TRENCH I ( TRENCHES MATE : PIT DEPTH
DIMENSIONS d/_ Jl
GRAVEL DEPTH FILL DEPTH OISTR PIPE DISTR. PIPE I I M IAL: NO. D UMBER OF WELL: BUILDING: V NT TO FRESH
BELOW P ES ABOVE COVER ELEVV INLLET ELEV. END, i PIPES: L11~ AIR INLET: FEET G.~i RGe NEAREST°M G_0 H
MOUNDS STEM:
Mound site plowed perpendicular to slope Check t e texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound ' ystems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets a riteria for medium nd. TIONS MEASURED.
❑YES ❑NO
IL COVER TEXTURE PERMANENT MARKS S: OBSERVATION WELLS
ES 1:1 NO OYES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPT OFT SOIL JSODDE SEEDED: MULCHED.
CENTER: EDGES.
YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH BENCH L TERAL SP Cl G RAVEL PTH BELOW PIPE FILL H ABOVE COVER:
DIMENSIONS
MANIFOLD UM MANI LO ISTR. P E A I OLD M EHIAL. N6. DISTR DIST I DI THI UI ION PIPE MATERIAL d MARKING
ELEVATION AND ELEV. ELEV.. DIA. LEV.. PIPES DIA.:
DISTRIBUTION
INFORMATI HOLE SIZE HOLE SPACIN r LLEDCOHHE TLY C VER ATERIAI VERTICAL LIFT CORRESPONDS TO APPROVED
❑Y ❑NO PLANS ❑YES ❑NO
COMM TS: ERMA TIES OBSERVATION WELLS: NUMBER OF PROPERTY WEII: BUILDING:
FEET FROM LINEN
NO ❑ YES CJ NO NEAREST
,t
1
7ool
A
Sketch System on Ret ' in county file for audit.
Reverse Side. SIGNATURE TITLE
DILHR SBD 6710 (R. 01
DEPAFTMENT OF APPLICATION SAFETY & BUILDINGS
'INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Mailing Address:
17-akoome- . r- DO
Pt>16'd !C
roperty Location: fiy,-\Lill~go.cr Town ' / q County:
h lc! t/a S 1/4S ~l /T,?DN/R / (or) W r
Lot Nu bar: BrkN Subc(jyisi n Name: Nearest Road, Lake or Landmark: State Plan LDNumber:
(If assigned) A
.gm l11 ! ,Svv G
19
TYPE OF BUILDING
Number of
El Public* E] Variance* ❑ Other,(specify)* Bedrooms:
1 or 2 Family *State Approval Required. 3 -
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY ooo
HOLDING TANK CAPACITY 114
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: G
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PR POSED (Square feet): _New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
2 Lf ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Narrie as isted on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Sig re: nM/MPRSW No.: Phone Number:
OC,~ (his-) 2516°5 i3S
Plum er's Address: Name of Desiigger-
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Agent: Fee: Date: Sanitary Permit Number:
/n APPROVED /Jl
~(y1J 7'~OZ~~O 7 ❑ DISAPPROVED Q
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
,DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
~~orne. Foods
t f 1.0y' -0/5 EXI -4w.0- 9 T 30 Nlg lk'w c~!7mpre -
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
' I~@UST(iY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TO SHIP OT NO.: BLK. NO.: SUBDIVISION NAME:
n w /T p N/R j (or) W n n,y
COUNTY: OWNER'S BUYER'S NAME: AILING ADDRESS:
ST. Te- we & I
O t
USE DATES OBSERVATIONS MADE
[iResid,,ce NO. BEDRMS.: COMMERCIAL DESCRIPTION: ~y PROFI DESCRIPTIONS: ER ATION TESTS: 3
/ ~1New ❑Replace
- - 2
RATING: S= Site suitable for system U= Site unsuitable for system 2
NVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOL IN ANK: RECOMMENDED SYSTEM: (optional)
ES Ou IES ❑U ®S FA [IS RU EIS 2l! Co
If Percolation Tests are NOT required DESIGNATE:
/ If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: Feces PROF LE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER- CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHJIIf. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
g O-
Z
B-3
-
66/ _54 - z, ' -,RA, iL
i S- 13t)
-
B- C3O O1)2 } L - - ll~ . 4617 bn5
i
B- S~ I9 a - e -
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PERIOD PER INCH
P- n o/
P- 2 /I on
P- O S I S
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.
SYSTEM ELEVATION z
-l- -
3~_.--
' _ -
V [_d
0 r"411
i
ISgv -'~j y~ t I I l
7 '
E
! ( I ~ ~ ~ W 3 1 Ni~i
i
i
3 ~
i
1, the undersigned, hereby certify that the soil tests reported on this fo~ rn were mad 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 (prin)t TESTS WERE COMPLETEp ON:
~O CU
A R SS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
u-1 VIYA onr) LAJ L~c_ 5- '5- iT- 1 2 V(Q 5-
C =IGNAT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) -OVER -
x~
..JCTIONS FOR COMPLETING FORM 115- SBD -6395
To " 7mplete and i,, iii test, your report must include:
lo-fl descril
2. Tt i , ion rn wheth( - 4ris is a resid( or cow ier :)ject;
3, MAX' ".uml- _ or corer" e plannei ;
4. Is yYGJTI;
5. CC n iq :poxes. A' 3 SUITABLE FOR A HOLDIN IF ALL
CJ'." :)LED OUT I ON SOIL CONDITIONS;
B n here for ~iriting profile descriptions cc plot plan;
fA LEA _ i e y IOC g yOur test locations, v A
hPPi rr + J,.,:
y l e' i> Terence point are G
xes as to dates, addresses, flood pk," i I p-
: h as flood plain, elevatior,) do^S n~* °'ply, p'"--^ T th( )x;
1 i . your current address and ye :ir : ic. tion n
1 "'~strihute as required. ALL SOIL TESTS MUST BE F- THE
IT: HN 30 DAYS Of. COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soi* Textures Other Symbols
BR - l
1011) SS -
lei" 3"} LS - Li
Hf - 1-
F'i a <
t
Bidg -
sl "n
y
L irn R
'In tnot
r vv,
!
fr7
cc -
M Cj
H 4y l_ - F
BM
VRP TC Oi'fN . ;
i
Form - S T C 100
A
Owner of Property 4Ter0-" e. ~h fer pr, SAS
Location of Property -tlfl,,C. Section 9 T jQ N R_W
Township C- w►O h o~
Mailing Address
a~ r
Subdivision Name AIa., e
Lot Number OAY
Previous Owner of Property__ .2ro r ,t o r, ,6o 1aC x_
Total Size of Parcel 35 ~c c. e S
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey Map
.Dead
.Land Contract, or
.Other legal Document which describes the property
PROPERTY OWNER CERTIFICATION
1 (We) certify that all statements on this form are true to the best of my (our)
knowledge; that 1 (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty ed record a Office of the
County Register of Deeds as Document o. 36 9 Wand that I (we)
presently own the proposed site for the sewage dispbsal system (or I (we) have
obtained an easement, to run with 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 f OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DAED T DATE SIGNED