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HomeMy WebLinkAbout020-1124-60-000o o o o o � x N C ^! } N N C £U ` ou 5 C U O N C N N > N Pv Y L L O 0 O V M 0 C C y° E r E d �+loc�� . N. c = a'n M w O oCi €x�-_ 0 0� 0� �c N Cy0 C .N JG Gc OC U. 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O t.0 oN CD w V) w !D V I CM O A C+ Q• ip dC• z_ w O I cn b x w rh rn w m y � o• o cD E C+ .7 V :r ;o (D N• y a STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS `/i2 .471ZEy ��NE SUBDIVISION / CSM# GG6 �� Del / LOT C/i�3 SECTION 2 _T0?1?_N-RAW, Town of (,.)Es buj ot oT ST. CROIX COUNTY, WISCONSIN 54 )P" I I' A 7 6, 1 PLAN VIEW EVERYTHING WITHIN 100 FEET OF SYSTEM By zot 'is3 1 JFNTS Alorr; /I14rA cz.*srreS ow,v i It r/G jL-cNT .La7S, I I i lif/u��SE �/b5n/iQr'i� ,QfE4 �EE4s'T �_ 1 ' A!U/0 ;A4,G1Cq. r - - Eltlsr'A S/I I 21WJ jf 1 I .NE I � g0• — 1 Er i STu�Jc, ♦� ,' `�, I Peon I � �qAiNci�ca �� 1 ;ut ,� � I BENcN.IU1iK- TOP 4w -<rAvc i-,owr No<f !o'14 E410-/00:0 E /sy •r S«,Td A&may •4,,AW .2/0' To %.40 KR,+7tzft, AAAJE SAG• c T.A,K frIstiNL ARROW Provide setback and elevation inform on reverse of tFiis form. Provide 2 dimensions to center of septic tank manhole cover. ,4o7- f S�2 BENCHMARK: zo� o f SE / / /C 7fiy. MA A/u F 16V E 4- �o 0 oc� ALTERNATE BM• SST/NL SEPTIC TANK / / N Manufacturer: �iEgE,p Liquid Capacity: : /.fop Setback from: Well Sri'' House 1,;2 • Other Pump: Manufacturer Model# Size Float seperation — Gallons/cycle Alarm Location IPEPcA<<�/�T SOIL ABSORPTION SYSTEM Width: S Length 51" Number of trenches S Distance & Direction to nearest prop. line: LJEsr G ' Setback from: well: /06 ' House 73 , Other foo, Fjo- Building Sewer ST outlet . 30, PC inlet — PC bottom Pump Off ELEVATIONS ST Inlet Header/Manifold %Y- 07' Bottom of system %S,</O' Existing Grade l oo.yo' Final grade Z _9a' DATE OF INSTALLATION: 9 PLUMBER ON JOB: LICENSE NUMBER: �'i�i%S 33SS INSPECTOR: 3/93:jt I Wisconsin Department of Industry, Labor and Human Relations Safety.and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Lounty: ST. CROIX Sanitary Permit No Permit Holder's N me: ❑ city Village Town of: MCALLISTIR, JEROME CST BM Elev.: Insp BM Elev.: BM Description. TANK INFORMATION TYPE MANUFACTURER CAPACITY Do G Aeration o ding TANK SETBACK INFORMATION P / L WELL BLDG. Air I to Vent take ROAD �/� a NA 5Aeration NA PUMP / SIPHON INFORMATION Ma Demand Model Number GPM TDH Lift FjjctTon TDH Ft Forcemai Length Did. Dist. To Well Cnil ARCnRDTInN CVCTFM Ci rVATInN neTe ax mho STATION BS HI FS ELEV. Benchmark 7 7a, Bldg. Sewer C Stif)IiIi Inlet I St/Of Outlet Dt Inlet Dt Bottom Header FMa - 13,!' j Dist. Pipe 3 53 r Bot. System Final Grade 0 BED / TRENCH Width I Length r No. Of Trenches PIT No. Of Pits Inside Dia Liquid Depth DIMENSIONSvDIMENSIONS SYSTEM TO P/L BLDG I WELL I LAKE/STREAM LEAC Manu acturer: SETBACK CHAMBER e INFORMATION Type < 0 A OR UNIT System: (�„� r11C712101 ITInki CVCTGAA Header „ Distribution Pipe(s) x Hole Size x Hoe Spacing Vent To Air Intake Length _ Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Syste_Mi,� Depth Over -, !/ Depth Over i - xx Depth Of I xx Seeded / dded xx Mulched Bed /Tranrh CanteF y� — L�r Bed /Trench EdgW- Topsoil ❑ Y ❑ No ❑ Yes ❑ No 1 ' i J COMMENTS: (Include code discrepancies, persons present, etc.) #LXiS �,X? cCAr1/-" LOCATION: Hudson.7.29.19W, NNW, SE, Lot 33,,Krattley Lane J _ O�lan r vision required? ❑Yes E3,No / O Use other side for additional information. / inspector 'sSignature Cert No Date -dCJ4r- ADDITIONAL COMMENTS AND SKETCH p SANITARY PERMIT NUMBER: �i" MMO� �— CA\IITADV DCDA/IT ADDI 1t%A1r1nL1 a ol��� W1 vvw a P1.. . . r§aEwa@ . I r . r.VI'a . 8Yvv s In accord with ILHR 83.05, Wis. Adm. Code C os STATE SANITARY PERhqT q —Attach complete plans (to the county copy only) for the system, on paper not less than ai$g3 ❑ 8'% x 11 inches in size. Check if revision to p evious application —.See reverse Side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION r �J�/a '/4, S T` , N, R E (Or PROPERTY OWNER'S MAILING ADDRESS LOT Ill BLOCK K ATE 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER t/ n N. TYPE OF BUILDING: (Check one CITY NEAREST ROAD State Owned O VILLAGE ❑ Public ®1 2 Fam. Dwelling— # bedrooms A Nu ✓v � or of — III. BUILDING USE: (If building type is public, check all that apply) r, o 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 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 D U U , "_o a %Y. /U Feet YO Feet VII. TANK INFORMATION CAPACITY in allons Total Gallons #of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. App New isti Tanks Tanks structed Septic Tank or Holdin Tank i Lift PumpTank/Siphon Chamber Vlll. 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 Sig ture: (No Stamps) -MiRMPRSW No.: Business Phone Number: �-r O Plumber's Address (Street, City, State, Zip Code): n IX. COUNTY/DEPARTMENT USE ONLY VAppro7vedD Disapproved Owner Given Initial Sanitary Permit Fee pncluda Groundwater �SurchargeFee) �J a 1 Wul 9t tamps) t- Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 IicensAd pumper whenever necessary, usually every 2 to 3 years. 6. 11 you have questions concerning your onstte sewage system, contact your focal code atlministrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Cheek 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. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total 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. Vill. 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 8'fs 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. ` i SBD-63M (R.11/BB) Aor 4 .o< I 4or 9.1 ljEw N( E6 *71 Alvm: A466oper,00i AfAA To 4,f Cpt-r a//NJJo ` gliMq��', I Pob� YnnoN APkA FE tI C , -. BENtNMA - T P of :SfPr,c Ti}NK M.4/lot£f�vER ;E<Ev. /vo.00' 5E on Sq'i G+ciS"r�NG �ESi4EN<E Al"r£: 4OTS 3.2-93- 3ti/ Aec <k �1EQ ey/%%,�ttiSTrlS Ex, Sn"vG G..,Lct FRESH AIR INLET AND OBSERVATION PIPE MAXIMUM 12' ABOVE FINAL GRADE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE MARSH HAY OR SYNTHETIC COVERING I I MINIMUM 2' AGGREGATE OVER PIPE DISTRIBUTION PIPE I = ELEVATION BED 6' AGGREGATE BOTTOM PER SOIL, BENEATH PIPE TEST IS - 3 •S/o' FT. 144 APPROVED VENT CAP 4' CAST IRON VENT PIPE SIGNED: 19l41W- PLOT do CROSS SECTION PLANS ZAPPA BROS. EXCAVATING INC PLUMBING UNIT Sf'f rA'*-1 4or 32 fi4sr .(or N VIA E +NO s SCALE LICENSE: It IA s DATE: 12 / A; TEE SOIL T STING BY: 1 {it��ES' � Joifiy Sa.c. • PERFORATED PIPE BELOW • COUPLING TERMINATING AT BOTTOM OFSYSTEM Wisconsin Department oflndusby, SOIL AND SITE EVALUATION REPORT Page lot 3 labor andJ-luman Relations urvrsron oraawq a ouiaryo In accorct wlm n-nn oa.ua, rna. nun,. wuv COUNT/ �s Attach complete site plan on paper not less than 8 1/2x 11 inches in size. Plan must include, but PARCEL I.D. >s not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION PR PERTY OWNER: /� Mc ALL, S?� PROPERTY LOCATION Q GOVT. LOT N W 1/4 sC 1/4,S 7 T Z� N,R E (or) W � 1vt PR ERTY OW ER':S MAILING ADDRESS t,QT BLOCK $ SUED.XME OR CSM h t4414Le firDG� — 1Z �./4ru)' CIIS� STATE ZIP COD PHONE NUMBER SA �� EST ROAD []CITY ❑1rIL GE� OWN Nlf CA-VTL� JAr4 c Nc/�sa� � ) ( ] New Construction Use pQ Residential / Number of bedrooms (] Addition to existing building P( Replacement [ ] Public or commercial describe Recommended design loading rate bed, gpdd/9-0.6 trench, gpolft2 Code derived daily Dow gpd bed, 112 trench, 1112 Maximum design loading rate O , S bad, gpd/D2 v ._ trench, gpd1(t2 Absorption area required Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations It Parent material Flood plain elevation, it applicable $ =Suitable for system c ENTIONAL i 5❑ U ND S❑U IN ROUND PRESSURE WS ❑ U AT•GRADE 8JS❑ U SYSTEM IN FILL fF9 S❑ U HOLDINGTe ❑ S U= Unsuitable for s stem Ground elev. r&L�4L Depth to limiting > factor Z5 Ground elev. 10O S4 It Depth to limiting factor .... ..�nnsrnrrn� vcvnvr Horizon De th P in. Dominant Color Munsell Mottles Du. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Y Roots GPD/ft Bed iench /� IS p. _ L 1 r rn Z. O.4 O g s 2$ /OYI�'{ 4^ — '!Si L 2 n, slot- /►,i r a 2) O.� �.� r "a#-IZ01qS ARK /nc.ArdA TN�U4NWr AMim MW Man Remarks: - HORI2o"JT ARW COc.Fv ICw �NCW�+•. r.. i Name: —Please Print Phone: 7c% O Q DST aevc� Mtv � J oC]11 ress: W I Date: 2y /g QCST Number: AIZ+ Spnature: a 7� PROPERTYOWNERIL#k +LLIST&Q SOIL DESCRIPTION REPORT Page of -PARCEL I.D. 2 Ground elev. j �•ld4 Depth to limiting flavc > 12.75 Ground VA M No no Remarks: 4p2,l2A►3S ARC LOCA f& T4kOC4AWT 191 �100_M?J MA M. Remarks: & 14a2.I20 rJ S A izo� LOc-o -r m -rm koUG N OUT Remarks: SBD-8330(R.0542) VI'.. i tit►` STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER �—, e I l u� t✓ L M L A 1.1i Jc4 MAILING ADDRESS `E Kru E e j La rye. E� XA � � o n 5 4-o PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE 11 t'n.C4 s L 1&' PROPERTY LOCATION �/i/u 1/4, C 1/4, Section Q_, T o1C) N-RCLW TOWN OF H,n y5t\ , ST. CROIX COUNTY, WI SUBDIVISION EA!` It- R i ti LOT NUMBER 3 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. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: c lam. 4- DATE: �I 1 CT St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 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. ------------------------------------------------------------------- Ownerof property 11j«-06"'< VA 4- HU 1 e- LLocationof property�j,,,/l/4 5 r- 1/4, Section Of] jT_2_LN-R I cLW Township_ Atio.-, Mailingaddress `H-� Krck+f(,' Address of site 5 A rr\c-� Subdivision name VIA c {` I d � C' Lot no. 3 '3 Other homes on property? Yes No Previous owner of property J o 1, n I Total size of property ,5� AcrrC' Total size of parcel 307 i9�ncr Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes '-, No Volume �8tL" and Page Number llq as recorded with the Register of- Deeds ---- �------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 4 3SS 1?i , 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. Sign ture of Applicant Date of Signature Arp—pli ant _ 7-7-y Date of Si nature • S 81 N LAND SURVEYING • HUDSON , WISCONSIN 54016 (715) 386-2007 Nome First Federal of LaCrosse Address 210 South Second Street Hudson, WI 54016 oescription Lot 32 and 33, Eagle Ridge in the Town of Hudson, St. Croix County, Wisconsin. (Jerome W. and Hope L. McAllister) N W E S PLAT . DRAWING This is not a complete Land Survey N 890261E 200.99, 290.00' 1 Lot 33 Lot 32 �W'X121 ! o J rea ^, Co s _ House c c N � 1 2m M = 24.51 c o O z j°° Garage z cc CAI s 290.14I U.G. Utilities N 87 49 C1 - n 'Sfl*i30 N KRATTLEY LANE i The location of improvements on this drawing are approximate•and.are based on a visual inspection of the premises. The lot dimensions are taken from recorded plats and deeds of county records. This drawing is for informational purposes only and should NOT be used as a complete Land Survey First Federal of LaCrosse has agreed to waive the minimum standards of AE-5 Mop No. 88-01-17R Drown By R R Scale - 1" = 100' 5/31/88 m 6,z 3,� § / ZID 7 fm ; � 2£! CD / 2 � � ) § ■��± ;8] E x. z # I.�i}£ ) 3 0 0 0 q»A 99, a IOE S± �E fa/ ° Ln kFF ) 7• 3qe\ sf ()\ E UD U) ! §d} "WINK\ §M ;wCL §;■ Z ,, 0,00 -. §� §m o & .. =44 228 O (� �- � ( \ }z( '•Pe , §�� | 2\ ) m2 § � � % \ � § % e \ ( Parcel #: 020-1124-60-000 0511a2005 10:04AM PAGE 1 OF 1 Alt. Parcel M 07.29.19.562 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): • = Current Owner LEE C & MARY JO NEUSCHWANDER ' NEUSCHWANDER, LEE C & MARY JO 412 KRATTLEY LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): • = Primary Type Dist # Description ' 412 KRATTLEY LA SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.590 Plat: 1925-EAGLE RIDGE SEC 07 T29N R19W EAGLE RIDGE LOT 33 Block/Condo Bldg: LOT 33 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 2000/398 WD 07/23/1997 814/119 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.590 34,700 204.400 239,100 NO Totals for 2005: General Property 1.590 34,700 204,400 239,100 Woodland 0.000 0 0 Totals for 2004: General Property 1.590 34,700 204,400 239,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 111 Specials: User Special Code Category Amount Total Special Assessments Special Chargaas Delinquent Chargas 0.00 0 0 RRPORT OF IIISPECTIO?I--I'sIDIJIDUAL SE6IAGE DISPOSAL SYSTEt•1 Sanitary Permit State Septic, - At TOWNSHIP fit: roix ounty SEPTIC TA7TK Size O�V_ gallons. `:umber of Compartments , Distance From: T-jell �— ft. 12% or greater slope ft Building _ft. Wetlands t �-- f t �\ Highwater ft. DISPOSAL SYSTmi _Tile Field or Seepage Pit(s) Distance From: well ft. 12% or greater slope eft Building 9 ft. Wetlands - fr. FIELD Highwater ft. Total length of lines41� ft. Number of lines_ Length of each line ft. Distance between lines ft. Width of the trench ft. Total absorption area 8 8 sq. ft. Depth of rock below tile 1_Z4n. Depth of rock over the <- in. Cover Over roc:/in - {i Depth of tile below grade �-in. Slope of trench ,er 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS. Number of nits is ame'ter ft. Depth below inlet _,ft. Gravel aro _yes no. :Total absorption area q. - ft. Square feet of seepage t ch bottom area required _ Square feet of s age area required •' Inspected by: r_• f' Title: Approved ( Date I 197.rl Rejected Date 197 r � oa PLB67 State and County Permit Application for Private Domestic Sewage Systems 'DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required A. OWNER OF PROPERTY B. LOCATION: Subdivision Name, State Plan I.D. # State Permit* County Permit s1# County s . Mailing Address: A/W 3�- / .4 `/4, Section ., T&jjN, R/ 97 (or) nearest road, lake or landmark Blk# TYPE OF OCCUPANCY: "Commercial "Industrial "Other (specify) Single family OK Duplex No. of Bedrooms_ No. of Persons- City Village Township !s S10A1 D. TYPE OF APPLIANCES: Dishwasher -,& YES NO Food Waste Grinder X YES —NO # of Automatic Washer _,K_YES NO Other (specify) E. SEPTIC TANK CAPACITY^/p 06 Total gallons No. of tanks 'Holding tank capacity Total gallons No. of tanks New Installation x Addition Replacement Prefab Concrete x 'Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1).r2)_y_3)_f Total Absorb Area sq. ft. New Addition Replacement 'Fill System Seepage Trench: No. Lin. Feet Width Depth__ Tile Depth No. of Trenches � Seepage Bed: Length _Width Depth Tile Depth 3� ^ No. of Lines j_ Seepage Pit: Inside diameter Liquid Depth Tile Size P"i Percent slope of land Ci- jF*jr,;Z -,i Distance from critical slope O� 1, 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 ified Soil ter/o NAME Y C.- r Cv eow CST # So,r/(r" and other information obtained from t �1. _ pp\ Plumber's Signature MP/ PRSW# Phone #3 �� 20J� Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with i H62.20, including well). ­411111b N r, J J a JJ • I. W, .• /%rA.�Sk fi •%� Sty Pe.. L 40 Rss•`t�� P 23'xt/• 6ar►*6 P##1 eted 9E' Do Not Write in Space Bello ; FOR DEPARTMENT USE ONLY Date of Application % Fees Paid: State ID°D County � Dqto Permit lssued/Re*ated ( ) Issuing Agent Name &)O Inspection Yes_ZNo Valid# Date Rec'd 1. oounty (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 fill /76 • w x w Yke EH.115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH .' P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TEST / LOCATION: �Y., S&'/a, Section ?, T21N, R (r)aownship or Municipality ,zurr�-'�� Lot No., Block No. County j`S , �'r�±,•�( u ivision Name Owner's Name: Mailing Address: TYPE OF OCCUPANCY: Residence �_ No. of Bedrooms 7 Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: .�SOiIL BORINGS lol- 3 `-7 -? PERCOLATION TESTS 2_ — SOIL MAP SHEET AFg-S SOIL TYPE off ;7,0�� &f Gc - C;,`".-%;d i 1 S PERCOLATION TESTS TEST NUM- DEPTH INCHES CHARACTER OF SOIL THICKNESS IN INCHES HOURS SINCE HOLE WATER IN HOLE AFTER TEST TIME INTERVAL DROP IN WATER LEVEL, INCHES RATE PERIOD 1 PERIOD 2 PERIOD 3 BER 1ST WETTED SWELLING IN MINUTES MIN/IN P- i3r Sea f, Zo 2 2 Z s P- 'r ' /Z- 21v �f Cr Z b C O�%'er r%/ _/ 2X_ 1/z / SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B_ l E" 00 7 I, 211 " ,0 )s„S �• .. s of if 6 e- 7 fr .71 • rS_ Aleo-1,•� S PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) y N i, uie unuersigneu, nereoy certlTy mat the sou tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. 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