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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER &,t2 4JdtV
ADDRESS RUPIN
SUBDIVISION / CSM# LOT # 3
SECTION 2.4( T 9f N-R 10 W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTVING WITHIN 100 FEET OF SYSTEM
(l!.
re
1141 CATE 2l W
rs AO
Provide setback and elevation information on verse of this f'-
Provide 2 dimensions to center of septic tank m~-~ e +cove_. r
\ 1
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3 / 9 3 : j t
Wiscc?ii~in Department of Industry, PRIVATE SEWAGE SYSTEM County:
La,4orand HIiman Relations INSPECTION REPORT ST. CROIX
,Safety and Buildings Division
• (ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Pea8kiiie{~fya' eD ❑ City Village R Town of: State Plan ID No.: AN HUDSON ngt)-1269-10-0
CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.
/dc`),~ , 60 Z~
TANK INFORMATION ELEVATION DAT 53
TYPE MANUFACTURER CAPACITY STATION HI FS ELEV.
Septic Benchmark
i /
Dosi g 16 , -3
Aeration Bldg. Sewer
Holding St/ Inlet
-T K SETBACK INFORMATION St Outlet _-2, 9,~/
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet /
Air Intake
Septic NA Dt Bottom
Dosin NA Header/Man. r f~
Aeration Dist. Pipe
Holdi Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Demand M ohs T.
o? S6, e S 2- 2-
Model Number GPM
TDH Lift Friction S ste
oss Fc rmemai n Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length i No. Of T nches PIT f Pits inside Dia. Liquid Depth
DIMENSIONS J~ ,,d DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufactu
SETBACK rer:
INFORMATION Type of I g &ay, C R UNIT Model Nu .
System: 1_4j-, ' c
DISTRIBUTION SYSTEM
Header / Manifo)d Distribution Pipe(s) ~ x Hole Size x Hole Spacing~Vnt Intake
Length aJ 5 Dia. ~ Length ~ Dia. Spacing A~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade tems On
Depth Over / N i r Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
B4,i~Trench enter P K@-44-Trench Edges f Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 24.29.19.1320,SW,NW,LOT 23, TTON HILL
e-4iy( f''.. ' .
~ l e
/~Yl.c„~=i.Gr~-. L,c-v1 7 ~'4"?.`-~•? ~o~_,A.~. / ~~c_1Cti 1
Plan revision required? ❑ Yes [2-<c
Use other side for additional in~/ffoormatio S 191'~.--
SBD-6710 (R 05/91) -~,5 ~ ` `"Cy Date Inspector'sSignatu a Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
-71(,l 7371
'Xen
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code Co n _
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1~ I &Tb3
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
.5V Y4 ~Y4, S T,2 , N, R Q E (Or)o
0 -a
PROPERTY OWNER'S MAILING ADDRESS ' LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
, CITY NEAREST ROAD
II. TY E OF BUILDING: (Check one) ❑ State Owned VILLAGE: h~.,7~4eAl "All e4l,
❑ Public ®1 or 2 Fam. Dwelling of bedrooms 'Y- L NUM )
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
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. ❑ 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 M 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) ,SQ '77ELEVATION
.S
SQU' ~~'®v r Feet Feet
VII. TANK CAPACITY ite /of
in allons Total of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank o2 -9-1-- - ~Ea
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: o Stamps) PRSW No.: Business Phone Number: J
r r r Y 715- )I-0G /2
Plumber's Address (Street, City, State, Zip Code):
O el
IX. CO TY/DEPARTMENT USE ONLY
❑ Disapproved Sa tary Permit Fee (includes Groan water Date Issued Issuing Ag t Signature (No S ps
Approved ❑ Owner Given Initial 40 1 :2.
3~ Q
Surcharge Adverse Determination / 71,0
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
_J
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.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete Dine 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.
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 3% 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; close 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)
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Wib,°asrinDe ntoo~ use' SOIL AND SITE EVALUATION REPORT Page /of
Division of Safety & Buildings in accord with Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x es i size. Plan lude, but
not limited to vertical and horizontal reference point (B ction f slope, or PARCEL I.D. #
dimensioned, north arrow, and location and distance t n rest
APPLICANT INFORMATION-PLEASE PRINT NFOIM Oyd~994 cs, REVIEWED BY DATE
f.
t
PROPERTY OWNER: S~ C OP~R'r L ATION
7100) S i= oi''E F, W O HL G CP1
kv~.k_' % W 1/4 04 1/4,S-2yT 2 N,R E (~'~L"~
PROPERTY OWNER':S MAILING ADDRESS L T' LOCK # SUED. NAME OR CSM #
Z ~lr' /ST ST- # Soo R i D G-t
CITY, STATE 141,V • ZIP CODE PHONE NUMBER TY []VILLAGE WN NEAREST ROAD
41o• 5-1 • A40 / Y5 /or 6P/1) 773-.3.5•y f4uDS114UT-roz f}i(t PD
i
[.f'New Construction Use [Residential / Number of bedrooms (J Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow (oyb gpd Recommended design loading rate ti bed, gpolft2 • 7 trench, gpolft2
Absorption area required N r _ bed, ft2 I.Q trench, ft2 3Ma)imum design loading rate _bed, gpd/ft2 trench, gpdfit?
Recommended infiltration surface elevation(s) Ste- Pa ft (as referred to site plan benchmark)
Additional design / site con ' rations S EE " 0rd.S~ - 4rTA C.d._9.
Par material Sc5 9 4~A'41.J 54T/PE - s'%t Flood plain elevation, if applicable N- 4 • ft
S = Suitable for system g J 0 2S moublo ❑ U IN G~N❑D U ESSURE AT915-13 U SYSTEM IN Fl CIS ING TANK
l
U = Unsuitable for system l~5 2S
Al
41PItZ A41-F SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. ;z. Sh. Bed re rh
.Y' o
-/J.- io k 343 s:/ /,f, sd,~ ~-F~e s z-fi 4 • S
Ground 133 to Yle 0 s e, C. ~ie ~,t v,F~e c s • 7 • -2 2t
elev.
ft. c -~-S YR y/lam S , S s v~, s6K nM-F i t q.s - • 3 • y
Depth to ~l D 1411• S U~ Y
limiting
factor Qy'f - ~i FS? P814,41'A' f--, 6, 5) 0-4-1 y"e_ x52~,->
Remarks: ~STiE'lol`~o N
Boring #
3 Sr / 4 f, 56,e /m Ae s Z`f . 9r • S
>x n ,k A -9 !O Ye 31
y)e 2- 1.4k 7n~e C3- If 5
Ground B 3 PLI 3 M X0_ 'v is D,C, f e 4. UY~iC' CS ~ • ~ ` • ~
elev. It C ft 31' 7v 7• •s YA 7 ~ S' d4- A*t .P a. S
.
.
Depth to {~gCn
limiting
factor
'71)
Remarks:
CST Name:-Please Print ~P& ERA-- 7,14el*-c, Phone: 71y^, 3
Address: K d :v.efl 110-vSo,.) 40;. SYo/G 3 -23 - 7 CSTiiIJ 2_9"S12_
Signature: Date: CST Number:
w~'d~ ~s 3 - z~- Pt`s
12 w E -le r=- opEo 6~9 .
ORIGINAL
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of
PARCEL I.D. ~r Z 3 Svc iPiDG~
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sig. Bed tench
[21 0-/3 /0 VX 313 - s./. Af Sbk ,w•f~e 2-F Y s
116-3 /3'33 7yVP, yI(e 19 6~ A",7R AtvfR cs
S S-
Ground It C, 33`7c -7SYR 51 I•-F s5 )c P,
elev. ft. O -fo fAA04 cT'v~p D OleItt
Depth to
smiting
factor
70
Li I
Remarks:
Boring # A p_10 /a ye 313 s6kk- ,~,fke S z~ . Y S
~XL /0-/,5' /o y,2 z, ski , SdK A4% `F R C S P f- . S . Co
13
+ s-1 .s R y14 sI J f, sbA~ A.fP, C-
s - y S
Ground
elev. (33 - p 7 $ y~ _ S 0, y 9n~►►~v f y C S • . 8
ft.
It G O -y7 7 S %1R y 6 She ,w,-F 12 Q s Y. S
Depth to fi46V A~
limiting fie X 7-56 7-5 yR f16 f G 51 ~1f, 9R v 4 S
factor N
5(1 &A R -7 7-5 Y9 y~y s 3' p5* s~~ L 56p, ~►y► S_ S
Remarks:
Boring # fR G~'P/F,~> L.¢ yE72 /9730 tvf- CLC` a
000
P,•T / Si.~l.'l 00Y7t--
Ground
elev.
ft
Depth to
limiting
factor N,. I
Remarks:
Boring #
4}' w~tiii
W. •
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
00M "gnlo nCIA11•
f'l f
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ULBRICHT & ASSOCIATES CO.
655 O'Neil Road • Hudson, WI 54016 Reg. Designers of Engineering Systems
715-386-81$5 Private Sewage Consultants
NOTES
A new area was soil tested 3-23-94, and verified by the county zoning
dept. 3-29-94. This is the area designated B8-B9-B10. It meets the minimum
requirements per code for a conventional inground type septic system, i.e.
depths to either seasonally saturated soils (permiability restrictions) or
fractured dolomite.
Soils (ls) near the surface are well drained with good structure and
consistentcy that will allow for uniform lateral hydrological movement
across the existing natural 12% slope, using long narrow trenches with drop
box distribution following the hill contours. Trenches may need to be curved.
In order to provide for a pR operly functioning system in these soils
the following basic requirements MUST BE MET:
-(1) Trenches shall be carefully excavated at precise shallow depths
(suggested system elevations indicated on plot plan, page 3).
(2) The installer shall exercise extreme caution and concern in preparing
the actual trench excavations prior to placing the high quality washed
aggregate into the trenches.
(3) The installer must carefully remove all backhoe bucket smears across
the trench excavations by hand raking the sidewalls and bottom areas, exposing
the natuaral soil textures. All foot traffic compaction on bottom must also
be raked away.
These precautions will maximize the absorption/teatment process of the
effluent for many years to come.
Although the is stra~a in which the trenches shall be excavated have a design
loading rate of .8 GPD/ft , this high factor cannot be used. Trench excavations
will most likely penetrate the finer sl stratas in many places. The trenches across
their entirety will, of course, be directly above this finer sl strata, in some
points, by mere inches. Thus, a design loading rate of .4 GPD/ft2 is required as
a minimum. This will require 4 trenches each 5' x 75' or 3 trenches each 5' x 100'.
Since trenches may need to be curved to correspond to existing slopes, trenches will
need to be carefully layed out using a level prior to actual digging.
~of
P
id Depart Human ment of RelationIndustry,
Labor bor and SOIL AND SITE EVALUATION REPORT P~ - of
L s
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 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
. Ur~Ct1 v GOVT. LOT 1/4 1/4,S T N,R E (or) W
PROPERTY OWNER':S MAILING 46DRESS LOT # BLOCK # SUED. NAME CSM #
a3 IN
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE QFOWN NEAREST ROAD
[ ew Construction Use Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpolft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Mabmum design loading rate bed, gpd/ft2 trench, gpdtft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baxxiary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
4tt.:>
Ground ,a rr SC>lC .~1'I
elev. m
(P 65 01 v -k" ~E
.
Depth to 4(Z-'756 CS
limiting
factor 5(.--6,/ 6 41 4 /.5 ' p, h
C' /1A
J--,e
Initial: Date 3 3 9
sue. _
ER OF SECTION 24
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71
Ir
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
b e~
~ J H.
LJi16 (x.1 0
0
OWNER/BUYER 0-
• ,fir` Fire d
ROUTE /BOX NUMBC Numberrza-
R ~
CITY/ STATE , r~ E ~,C~' ZIP~16/G~~
PROPERTY LOCATION: Section Y T_ , R~---W.
Town of j~t~~SG'1 St. Croix County,
Subdivision Su"~YLJ IC Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
o. tmeesepticttank astaitreat-
if needed an aaffectsthe8eunctiontank
the system c
ment-stage in the waste disposal system.
St. Croix County residents-MaX be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
wh -c 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 s s~ t.ems agree to keep their system properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
nec-
operating condition and •(2)•after inspection and pumping
less than 1/3
essary), the septic~~llkbe is
Certification form
three year-expiration. y
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein as.set by the Wisconsin Depart-
ment of Natural ResourceC~oixe ,CountyaZoningo0ffiuetwithinm30edays ~
and returned to the St.
of the three year expiration. date.,
SIGNED
DATE -
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
• APPLICATION FOR SANITARY PERHIT
• 8 T C - 100
This application form Is to be conplatad In full and Signed by the olmsr(s) of
the property being developed. Any Inadoquacles will only result In delays of
the pzrralt Issuance. -Should this development be Intended for resale by
owner/contractot,(spee 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.
Ovntr of property ~\an,c C U3e-,-q
Location of property 52 1/4 X1/4, Section -,9Y T AI-R V
Townshlp 11ttc1SQ
Meiling address 'le
Address of site
Subdivision news. Stx^ r(ej
Lot nunbat _
Previous owner of property SCA-,~.e S P",
Lt S c-
Total size of parcel
Date parcel was created
Are all corners and lot lines Identifiable? Yes _ f10
Is this property being developed for resale (spec house)?_~_Yes 1t0
volume /0,3L
and Page Number 16/ ..a recorded with the Register of Deeds.
---------------------Sac ufi 505?/9-----------------------------------
IMCLUD9 VITN THIS APPLICATION THR FOLLOVINCt
A VAARMT1 DRID which Includes a DOCUNINT MUUIR# VOLUM9 AND PAOt )(UNAIR, and
the BIAL or Tilt RH0I8TBR OF DEEDS. In addition, a eettlfled survey, lt.
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Castlfied Survey Hap, the Cettifled Survey
Hap shall also be required.
7
PROPERTY ONNER CERTIFICATION
I(Vs) rertlfy that all statements on this form are true to the best of my (our)
knovledgel that I (we) am (are) the owner(s) of the property described In
this Intormatlon-form, by virtue of a watranty deed recorded in the Ottece of
the County Re9lster of Deeds as DOCUment No. - ~5QJr 712 . and that I (we)
presently own the proposed site for the sewage dleposal system (at I (we) have
obtained an easement, to tun with the above described property, for the
consttuctlon of sold system, and the same has been duly tecocded in the office
of the y y eg a ec of Deeda, as Document o. Sa S 71p
L
o ~ I
I 9nature o Owner lgnat re of Co-Owner it A pllcable)
Date of 8l9n4ture Date of Signature
'DOCUMENT NO. WARRANTY DEED THIS !PACE RESERVED FOR RECORDING DATA
SU5'719 STATE ]PAR OF WISCONSIN FORM 2-1982
aJ VOL 1035PAGE 81 P.!:d wR'S o RcE
%~c~% r. D.. %141
Greenwood Enterprises, Inc., ..Wisconsin Corporation, sr. C
Rea•dfm Record
SEP 1 T 1993
ie at 2:35 p n
cony y and warra>?ts to Daniel
WoI~berp, ! s and and. wife; " aiiivivorsTu'p matitar"p=oiler
RMS'a► nl DReft
RETURN TO
• Heywood & Cari, S.C.
the following described real estate in St, Croix P.O. Box 229, Hudson, WI
County,
State of Wisconsin:
Tax Parcel No:
Lot 23 of the Plat of SunRidge filed in the Office
of the Register of Deeds for St. Croix County,
Wisconsin on September 22, 1989 in Volume 5 of Plats
at Page 71 as Document Number 451750.
D..
F°
This ._.is not homestead property.
(Is) (is not)
Exception to warranties:
K
Dates this . ...r say of September .....-----•---•------93
cr •
..-(SEAL) ' Q.:;jSEALjm,
James E. Rusch, President Mar Rusch etarV/ asnfer~J
s
1W1~ 2
(SEAL) • -
its ..c:..:
AUTHENTICATION
ACHNOWLSDOMSNT
Signature(s) -.IsmeB-E..-Bilge z,..PxesidezLt-..•-____ STATE OF WISCONSIN
County.
authenticated this _ ._---day of.--September 1993-- Personally came before me this • ....day of
._September 1993... the above named
•__..._Jialtex._}losiyn,gky_____________________________-__- ch Secretary/Treasurer
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
authorized by 1706.06. Wis. State.)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Heywood. ~ Cari S.C_ b Walter Hod sk
P.O. Box 229 Hudson, WI 54016 u~
St Croix
Notary fbiic County, Wis.
(Signatures may be authenticated or acknowledged. Both Mdate: Y Commission is permanent. (If not, state expiration
are
are not necessary.)
of persona signing in any capacity should be typed or printed below their signatures.
WARRANT! DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
FORM No. 2 1982 Milwaukee, Wisconsin
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rliQCAtXQ~rtM*IMQB.g4.29.19w,ow ivRTE;S~ IV/ 6E5 5T~~1 Circle County:
Labor and Human Relations INSPECTION REPORT
SaSety and Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
,GENERAL INFORMATION
Permit Holder's Name: E] City E] Village El Town of: State Plan D o.:
ev.: Insp. BM Elev.: BM Description: ~i Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9400016
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
irIto ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Septic NA Dt Bottom
Dosi ng NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 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- I 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.)
LOCATION: Hudson.24.29.1,9jW,SW,NW, Lot 2, Hutton Circ e
2211 vm,~~ c~^~~~~~, C X7'1 C/
5TC -,/6V d aw
Plan revision required. ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
SANITARY PERMIT APPLICATION
.
aDiLHA In accord with ILHR 83.05, Wis. Adm. Code COUN
...~.,..,..,~..,,v,.
Cl/
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than El
8% X 11 inches in size. Ch/eck if a ision previous application
-See reverse side for instructions for completing this application. S TE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 3 - 4309 lv
PROPERTY OWNER PROPERTY LOCATION
Da -,,v zJi.4x,&&y 14r e~J %,l~ S a T N, R E (or) 41P
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
S t
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
11. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned VILLAGE : S a ~G.../ J c
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms =N W:
PARGEL TAX M
III. BUILDING USE: (If building type is public, check all that apply) Q a _ tr ;2~ /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
50 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. K New 2. ❑ 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 0 Mound 30 El Specify Type 41 [__1 Holding Tank
12 ❑ Seepage Trench 22 In-Ground 42 ❑ Pit Privy
130 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
Q~ ~O S' Q " Feet yr Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank ?G'a I NC ST'
__U+U I
Lift Pump Tank/Si hon Chamber 420 ezr T
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): :Plumber's Signature: (No Stamps P PRSW No.: Business Phone Number:
Ode), 11
Plumber's Address (Street, City, State, Zip Code):
&O•ar .
It C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sary Permit Fee (Includes Groundwater Date Issued issuing A 7&,re(N tam
Approved ❑ Owner Given Initial rcnarge Fee)
Adverse Determination At~
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
1, >
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 reneet,ai any new
criteria in the 'aV ,,:;:r sin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit iSSU`1g authority.
4. Changes in ownership or plumber requires a San tary Permit i sinsfer/Run rywal Form jSF") 6399) to be
submitted to the ,:jaunty prior to installation.
5. Onsite sew u systems must-be properly maintained. The tank(s) ina-st be Fui I in, a licensed
pumper whert~-:ver necessary, usually every 2 to 3 years.
6. If you have questions. concerning your onsite sewage system,, contact your local codes =,cfr:<,nistrator 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 arid parcel tax member(s) of
where the system ~s to be installed.
II. Type of building being served. Check only one and complete # of bedrooms i' 1 or 2 Family 0,uelling.
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, : &connection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absor- t;> ^ system information. Provide al± information requested in #1-7.
VII. Tan: ill in the capacity _-vor, rew and/or existing tank,
tanks an a n. Afacturer's name. ir;dicate -t! efab or site constructed ano e,atei ie,I C,)n t' '(,r all
t„.r s•i'>!,ar and holding tanks this system. Check exp«,irnc, rprova i : nks received
exp,F e'r-;cfi,ct approval from DILHF2,
VIII qty stwement. Installing plumber is to fill in name, iir.,e~~be res. n6e, with ap(-ro,- . prefix (e.g.
MF, etc.j, ldress and phone number. Plumber muEt sign applica'
IX. County; Del. artment Use Only.
X. County/Dep rtment Use Only.
specifications no nialier than 81/2 11 inche „<<: r .ubn,itt:> :rs r,ty. The
pia..Tv- n,!-s' IC I,~;l,J 'he following: 4) plo! ;aian. draw,,,, to scale -or wit1 of
PIOi a z t_~i f t;' tank(s) or other treatment tanks; building 'Z nr.'i ~i +r service;
stre:ov-~s Ar=-, iro e pump Or &IphQ-0 id0kv, distribution boxes; soli _{er t,- I.,, ;ygtF~r, t system
r1C 'i tc l
;,pn of the vv C;rl 4;arVeCC. ) horizontal
G) cc-noplete spec;tications for pumps and controls; close volume; e:et;ati e ence~: trip! •.r: 'oss; pump
performance curve; pump model and pump manufacturer; D) crass section : f 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 surcharcles (fees) for a um6, r of
reg l:,,ited prractices w, hwh cars fi fect g c:undw3fer.
The monies collected throudj'i . .>4e s "-ha,g_ tr ..;:kilt, ,?r rroni orif
wat4 :,orltaminiition Ir~G Nbf3 .t s't. IS ffirlri ugta '=C'tp( ,s,}. i`t .n r!t ar( _
SBD-6398 (R.11/88)
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f SAFETY & BUILDINGS DIVISION
4
State of Wisconsin
Department of Industry, Labor and Human Relations
September 17, 1993 201 East Washington Avenue
P. 0. Box 7969
Madison WI 53707
ULBRICHT & ASSOCIATES
ROBERT ULBRICHT
655 O'NEILL ROAD
HUDSON WI 54016
RE: PLAN S93-03096 FEE RECEIVED: 180.00
WOHLBERG, DAN
SW,NW,24,29,19W
TOWN OF HUDSON COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
n th Stiemke
Pla Reviewer
Section of Private Sewage
(608) 266-8230 7:00 to 3:45 Mon. thu Fri
SBD.7997 i R. O V91
R . d J . VlS .c.~
S93-03096-
PROJECT INDEX SHT.',ET
OWNER: -PfV Jl Env l,a2~F?e Gv o ffG 13EiF G- -7 7 3 - 15' 5 j.S"
ADDRESS ~/o f✓~ 2~~4 ~o ~vE. E Sr ~~vL~ ~li:~.✓. ,55'ja/
SITE LOCATION? Lo f- ,~,t z 3 S~~ (Z iLV(Siz-r Su 13 Di u [So,,-)
Scv, Nc,J, S~ Zy, T2-1 A-~, R i Q W Tac.v.,j of t-r uDSoA-]
PROJECT DESCRIPTION: S-r. cR~~ x co v.vey
2N OF
/ff 2 > 13 5 /3v7-
T~.~cTv,e~//y Ao - M
soy"/S SE~¢Sa.LJrt//~ S~T'v/~~'T~1~ . L ~'j"/PE-g s o,~
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~10L~n
-L>r4 ~ Y W A5-VF- Fl oL0 _ 400 14 IV&-k."
PAGE 1 PLOT IPLAN VI WS
PAGE 2. MOUND CROSS SECTION & SYSTEM PLAN VTEWS
PAGE 3. PIPE LATERAL LAYOUT
.PAGE 4. DOSING OR SIPHON CHAMBER CROSS SECTIONS
PAGE 5. PUMP PERFORMANC" SPECS OR SIPHON SPECS
PLUMBER -
DESIGNER c' o
DATE:
SIGNATURE: ` MBERTw. s
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Page ? Of S
7op OF /tt , TCPALS X03-60
Synthetic Covering
Distribution Pipe
Medium. Sand
s y Presi
r a Elev~T►~N
Topsoil = -
F 10 310
_3 I~ E p J.~
I 6 LEV~T►o J
jd % Slope uN~R I3•E~
Force Main ,Plowed
Bed Of
T to
Aggregate Layer
Uti~ v,P.H ToE' Gr'NF D A O Ft .
99. ~'G +S E / R Ft.
Cross Section Of A Mound System Using F •75- Ft.
- A Bed For The Absorption Area G 0 Ft.
A 8 Ft. H Ft.
r~~ roe ? he!o~~~ IhR c owoslopo go of the B G3 Ft.
i ' lei ~us1 remaia undish~rbed. K 12- Ft . ~
Solt ~bSOrpl10 y L g-7 Ft.
S4SIS 8 Ft.
p, SpaE f Ft.
ditto in W 3 V Ft.
Olt • I Observation Pipe
K --y
o y o
W
I._--~T-------
r
Distribution :Bed Of i
Pipe Aggregate
Observation Pipe Permanent M.arkees
y pv~ ~~tPpEv sfE~~ Ro.~s •
Plan View. Of Mound Using A Bed For The Absorption Area
~c~Qc9/~p~I~ • /3ff•,~'~L ~~PE ~ = OAiL SAS TE f/c~J ' - loo CJ
-oil /,v -6 /T/i t1-rw r
. P f
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Pao ~o ~~ts~-L
s
63 q _ /Co360 so FT
Page-3 0 f .5
• Void vo/vmc wok ZS Fr of Z ~'Uc FORD-Vol'
`93 030 96,
Axe /i45 T A0 le-
Perforated Pipe Detoll
~~,e,•Gti r v~cvnE
End View
)Perforated
End Cop) PVC Pipe
i. •
Holes Located On Bottom.
lY Are Equally Spaced
R
I
\ * PVC Force Main
/Q PVC it
Manifold Pipe
Alternate Poiltion Of
Distribution Force Main
Pipe
Lost Hole Should Be I
Next To End Cap
End Cop Distribution Pipe Layout P .30 R
ApIE SYSre R S U z s' p~w^ //S
S~
PR~VA?E allY
X y~ Inches
C
Y y~ Inches
'[1011 f
P~ HUMS ~5~
p g b «p ~ Hole Diameter Inch
V► gU
j OF Lateral / Inch(es)
s
Manifold Z- Inches
E CSR SP~NpENCE Force Main Z Inches
SE
# of hol es/Pi Pe R
Invert Elevation of Laterals /03'S Ft.
d/5TRi13UT/O~ l~is'G~i~,P E ~P~}TE CSR E~3clti IA TER / 9 3~, f /~+tw~. '
?Alt- OT i S Z
3 7
/4V
• ` To T~1. / ~ i s T ~ /3 u rio,~ a ~ S cti, A,e 4E ~9T~ F,e ~~~~o~,~ -
eD. ( 6, N /t, u ,k ~ s c in ~ W CrE- ,P~17-F a,=
t
S 93 ON 96'
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS pr}yE f OF 5;
VENT CAP
4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MAWHOLE COVER
_ w t.~l~ ~Al3E/
w N
> Ait
M DOOR.
WINDOW OR FRESH 12•MIU. SAGE SYS
AIR INTAKE PIR
/E~itT~On/ GR DE it 4"MIN.
TRADE ,
Ap/l
~ ft 1N
IE~~n• oti 1oN o
n N
L+~ INLET 4
L E c RR$®tVQ SEAL
~ 0 • D ~ 5 I Y r I I (i APPROVED .101NTS
APPROVED JOINT W/C.I. PIPE
W/C.I. PIPE o~ ( III ALARM EXTENDING 3'
EXTENDING 3' O ONTO SOLID SOIL
ONTO SOLID SOIL g g.15 ti5 > i I .
3y'' C3' I I ow
c
9l.9 ,
ELEV. FT PUMP-_ OFF
r
't AN K o~DOI 1 BLOCK
~/EvArio~J
RISER EXIT PERMITTED OIJLy IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPECIFICATIOUS
DOSE GlJEE~S *~G•l1-C /1'OD • I~JgER OF DOSES: PER DAy
TANKS MANUFACTURER: 15o
n :f" TANK SIZE FL L~ GALLONS DOSE VOLUME y
Lt UeL INCLUDING BACKIFLOW GALLONS
ALARM MANUFACTURER:
MODEL NUMBER: .D V L CAPACITIES: A= 5 'INCHES OR 100 GALLONS 411
M E R C v'P y F I 0 A r-
SWITCH TYPE: B n_ INCHES OR GALLONS
ZDE//Eie C = ' , ` INCHES OR /`s f,ALLO .+5
PUMP MANUFACTURER:
MODEL NUMBER:; 9~ %a H? Ito U Do 0 INCHES OR ZG.S GALLONS
SWITCH TYPE: rl J-jyRAGl= A"g1f6W1 f~10'47_ NOTE: PUMP AND ALAE:•'I ARE TO BE
SEPARATE CIRCUITS
INSTALLED i,U
MINIMUM DISCHARGE RATE 1/0 _GPM L~ ~-A,~~ SPECS .
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . 2.S FEET EALCA. Of Jf PltL
H- 25 FEET OF FORCE MAIN X 2'COZF/oo~FRICTION FACTO1t..p'~0S FEET 40rIS Zd•5 AIS•
TOTAL DYNAMIC HEAD = -5 FEET
RovNO ~7 f c
INTERNAL. Q;MEIJEIONS OF TANK: LENGTH;WIDTH ;LIQUID DEPTH
/
' ii ,
,t
t,l 93 -030 96,
N
HEAD CAPACITY CURVE 3 7/8 6 1/4
MODEL "98"
30 4 5/8
25 6
- 3 5/8
6 20 m
+ +
U ,
t 15 4 3/16
'4 4 i~~j ® I
10 -
a . 1 1/2-11 1 /2 NPT
2-
5
-
III !d .
0
U.S. GALLONS 10 20 30 40 50 60 70 80
LITERS
80 160 240
0 FLOW PER M114UTE
UW
`i
• - TOTAL DYNAMIC HEAD/FLOW PER MINUTE
EFFLUENT AND DEWATEFIING
ar. ,
I
V? CAPACi'IY 12
HEAD UNITS/MIN
FEET METERS GALS Li RS
5 1.52 72 273
10 3.05 61 231
' I 15 4.57 45 170 3 5/16
20 6.10 25 95
Lock Valve 23'
I
y.
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Electrical alternators, for duplex systems, are available and • Mercury float switches are available for controlling single and
r4 supplied with an alarm. three phase systems.
> P Mechanical! alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for
without alarm switches. variable level long cycle controls.
SELECTION GUIDE
1. Integral float operated 2 pole mechanical switch, no external control required.
Standard all models -Weight 39 lbs. - ,;72 H.P. 2. Single piggyback mercury float switch or double piggyback mercury, float
98 Series Control Selection switch. Refer to FM0477.
Model Volts-Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075.
M98 115 1 - Auto 9.0, 1 or 1 & 7 4. See FM0712, for correct model of ical Alternator, "E-Pak".
~4r
N98 115 1 Non 9.0 2 or 2 & 6 3 or 4 & 5 5. Mercury sensor float switch 10.0?25 used as a control activator, specify
duplex (3) or (4) float system.
098 230 1 Auto 4.5 1 or 1 & 7 -
6. Four (4) hole "J Pak", junction box, forlKiatertightconnection orwired-in sim
'E98 230 1 Non 4.5 2 or 2& 6 3 or 4& 5
pbx or duplex operation, 10-0002.
' 7. Two (2) hole "J-Pak", for watertight connection or splice.
CAUTION
For information on additional Zoeller products refer to catalog on Combination Starter, FMO514; All installation of controls, protection d
evicas and wiring should be done by a quali-
Piggyback Mercury Switches, FMO477; Electrical Alternator, FM0486; lv'-'mchanical Alternator, tied licensed electrician, All electrical and safety codes should be followed
Indud-
FMO495; Alarm Package, FM0513; Sump/Sewage Basins, FM0487; and Simplex Control Box, ing the most recent National Electric Code (NEC) and the Occupational Safety and
FM0732. Health Act (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is dfigineered into the design of every Zoeller pump.
MAIL T0: P.O. BOX 16347
LouisyiG;, KY 40256-0347 Manufacturers of .
SHIP 70: 3280 0. i'71d,ers Lane ~
E/1 L.
Louisvrr,r' KY 4u216 a` - UAl/7Y A MPS /NCE
9.~9
(502) 778-2731 FAY (502) 774-3624
V"
I
Wisconsin Department of Industry,
Labor and Human Relations SOIL AND SITE EVALUATION REPORT - Page -of
j
Division of Safety & Buiidirsas in accord with JLHR 83.05, Wis. Adm. Code
c~iv v - Ti ~r ' .GI/97Q~ /PUS h'- OUNTY
s 7,
• 'Attach complete site plan o.- paper not less than 81/2 x 11 inches in size. Plan must include, but
t
not limited to;vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D.;0
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVI(rVYtDBY DATE
PROPERTY eWNEERt 130 ,VAX PROPERTY LOCATION
74-W W 0 f+ L R E P_ CT GOVT. LOT 5;W 1/4 4/0, 1/4,6 ay T ),f N,R E(01 WW
PROPERTY OWNER'-S MAILING ADDRESS LOT # BLOCK # SUED. NAME QR CSM #
5qs' 70f1h~ lfde ' _~7- 3 -50A-) R IV&f=
CITY, STATE ZIP CODE PHONE NUMBER [)CITY [VILLAGE DOWN NEAREST ROAD
ST AfZ14 S5,101 (loll 771-3122- I-P v0.1'a•~ vTTa-~ 'flil/
[kt'New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building
[ I Replacement [ I Public or commercial describe--
Code derived daily flow gpd Recommended design loading rate ' S bed, 9polft2 G trench, gpd/(t2
Absorption area required -'/00 bed, ft2 Soo trench, ft2 Maximum design loading rate S bed, gpdi/(t2 ' G trench, gpole-
Recommended infiltration surface elevation(s) S-Q-e- 3 -ft (as referred to site plan benchmark)
Additional design /site considerations S~ i E S011-~/E_ O-vc~ ic-I,LO Af44AVD SySTE1-1
Parent material Sc5-, S1r W A /C".v - SILT ~~Di:~r~aT S Flood plain elevation, if applicable yam- It
S = Suitable for system ~VENTIOW I IN-GROUND PRESSUWE AT D SYSTW IN FILL HOLDING TANK
U= Unsuitable for s stem 0 S Gdv l!j W'S ❑ U ❑ S C U 0 S Bej 0 S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounfty Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mach
/ '4 d-/ /0 YA 3 /1_ Si' / Z,~~ f ~~k /►M ~~/e S 3 `F 5 , G
/y.; 7s r~ s/ Z.f Sb& fA s 3f 'S . G
Ground 2?-66 7 5 y/2 51& n~~ fr Q S
!J ,
elev. ft. 7-60 7. S y/e Y~7 s ' 2 S sdk /hd v 1 ` a ti~ 3 ~V
Depth to
limiting v M GU '
factor S~ / lU/f fGD~?/JO S /eE G . .
27
- OF
e -Y E- OC V /t
Remarks: _
Boring# 10
!/~3/z f f ZfSh ~f 3~ : S =
Z ,3 _ ?y ZS' ye 7/U, s. / , 56,E X11 f~ s 3 F s'
Ground ;
elev.
ft. A, A)p N
-
Depth to IfC t f ~ q W Go ,v /CA limiting
Remarks:
CST Name.--Please Print P /RER T W /3 9 l c-k7 Phone: 3~ 8i~s
Address: Ce s s t~ r N t Ld G, l , s4i0/ ( q-~ y '~1 ~2_
Nym
Signature: Date: ~O CST*
RECEIVED
gt"-b ROGbe 4v S E A.) COUAXtC 2 tv 4- 7- 3 Z ST CP0X'
COUNTY
z'~Nlrli;t
y
004
- SOi' S Aa ~'Svc.T'S iti
6 Y t IPe 5TH /'c 7/'ON , Soy/S
007- r.iV-y ~4 r Ti vE- h~ G . cv .
~rv~~°z~ ~ozvu wv p~•~t~'~3~ X
1?L9 r F>efl-1-1
o'er G
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Zof
PARCELI.D.# AO-~ # 3 SUAJ R 1.C)
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounty Roots GPD/ft
In. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed nnch
a-,& 1o/4 3 51 / '7-.-F, sk~ f,~ Zf , s
f 116 Yl'? Y13 5,1,1
' ~ S to
Ground f3 1.1q, 3 /z /e 5-11 .3 M, At A." f i ' es
s
elev. G -75 yA y 8/---~P, /s o, f fR /r,,, LfP", ez
4p- 7it
Depth 7 s 4
timib
n9
factor
Remarks: w 5 U1E)e Zoe P 0vot& ~
Boring #
417
Ground
elev.
ft.
Depth to
limiting
Remarks:
Boring # _ ~ey,~ 3/3 s./ 2,f, Sb& z f , S
/3, - 3~, io y 3 571*/ 3 rm bK n ,,f cs v~- s
131
Grd~
elev. 774
Dept, to
limiting
factor ,
Remarks: 5 I')"r 4 e w~ j U~eY 4x'- 7' P UZU l-4x .
Poring # _g ~"a ~/2 3~2. f~'/ z , f , S 6 K i►r+ fj2 - C S Z f • S - ~
At V-15 7, s W 11 S~ 2,~wr sbt (Y4 vf/Z c s z f s ,G.
[3
;3/ T
~,s R s o ~,s Cs
Gmund
f fie y 8 4A-~Dc,o S/ 1, f, k iw► o f l' a X, ~ AJp: A
Depth ro f32 7,514 f s2 ";r 1/fiE~ limiting s' /,f, /►,,of i
i,
factor /33 70 o 511 5ht )UP I N
T 70'' `i~4 cT v G~~t fay
2-& --F "I
5 Remarks: 70 W u
COM 0912^10 ^C M9\
H H
• m N a
`k, N 4 °
C)o V
oil.
Z
o ~
.ten
~O
m
o
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CR (
W ~
o
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7'~ ls~m W ~ ~ ~ h
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orb
~ILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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
S'A/ t/a a/t/a, S T„? , N, R / E (or
10CE _V 42 6 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
5"f s r
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
ate/ 5S"/ Baal rd
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
F] State Owned O VILLAGE ;
PAR L AX NU B t
❑ Public nn ICJ 1 or 2 Fam. Dwelling-# of bedroom
491-
III. BUILDING USE: (If building type is public, check all that apply) O aZ /Q
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. ❑ 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 K 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/daay//s/q. ft.) (Min./inch) C ELEVATION
G 6 ..S-d D . S AI il/04 - Q3~ Feet fu* 75 Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper. Con- INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete strutt ructed Steel
glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank -j V646 - L 1
Lift Pump Tank/Si hon Chamber ~~Fzejc'_TJ ' t El I F] El
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 Signature: (No Stamps) MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
A0 2 go e- e 4 oe wS
IX. COUNTY/ TMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater rafessued issuing Agent Signature (No Stamps)
❑ Appro ❑ caner Given Initial Surcharge Fee)
4q!Adverse Determination
X. ffiWS%yREASONS DISAPPROVAL: CJG
SB (formerly Plb-67) (R. 1/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at tha 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 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.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, 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.
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 B% 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; close 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)
[Z7j 'DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
rem w~iwer aw,wn<,w,e~
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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
L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
T,'r, , N, R rs E or i
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE : QSN ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms; PARCEL TAX M
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 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 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 s
V. TYPE OF SYSTEM: (Check only one) -
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 E Mound 3o ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 1,6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) f ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total # of fab. Fiber- Exper.
INFORMATION- New istin Gallons Tanks Manufacturer's Name Pre oncret Con- Steel glass Plastic App
structed
Tanks Tanks
Septic Tank or Holdin Tank
Lift Pump Tank/Siphon Chamber [ r13
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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 1 /
t
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/ RTMENT USE ONLY
ad Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
❑ APProved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: _
.
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
Y r
' e
r
' 'INSTR TIONS
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 renewakany now.
x
criteria in the Wisconsin Administrative Code will be applicable.:, .
3. All revisions to this permit must be approved by the permit issuing ai}thority.
4. Changes in ownership or plumber xequirps a Sanitary Permit Transfer/Renewal Form" (SBD 6399) ta,be : -
submitted to the county prior to installation.
5. Onsite-sewage systems must be properly maintained. The septic tank(s) must be pumped by y-a licensod_ +
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions cpnce ' rning•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'applic"on 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. BVilding 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, reconnectiort,.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 manufacturerls;name. Indicates prefab or site constructed and tank material. Complete for a//
septic, pump/siphon and holding tanks for this systern. Check experimental approval only if tanks received
experimental product approval from DILHR.
Vfft7Responsibility statement. Install irig-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% 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/waterservice;
streams and -takes; 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 s
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.
n2
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-ihvestigations and establishment of standards.
SBD-6398 (R.11/88)
~ILHR SANITARY PERMIT APPLICATION -
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
aaaaaa~ a~awm~ns
a~ ew.w,tue,a,an,wu~w.s~
mows • STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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
`-`,Ai t/a s,.:/t/4, S T,24, N, R E (or w
PROPERTY 6G NER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE 2!L~41 P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
: F A. 1(144 1 -;2?- lt
(Check one CITY NEAREST ROAD
II. TYPE OF BUILDING: C❑ State Owned ❑ VILLAGE
❑Publ R E AX UMBER(
ic Q 1 or 2 Fam. Dwelling,# of bedroom A
III. BUILDING USE: (If building type is public, check all that apply) J
1 ❑ Apt/Condo
20 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. Q New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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
ELEVATION
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 6
10 Ci - G) r- e, rf 'L ° rd. / Cl~f Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank L
Lift Pump Tank/Si hon Chamber 7
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 Signature: (No Stamps) #P7MPRSW No.: Business Phone Number:
i
umber's Address treet, ity, State, Zip Code):
ry J .f
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Issuing Agent Signature (No Stamps)
❑ Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF-APPROVAL/REASONS FOR DISAPPROVAL:
_ F
SBD-6398 (formerly Plb-67) (R.-11/88) DISTRIBUTION: Original to County, One Copy To: Safety S Buildings Division, Owner, Plumber
INS"rRU'CTIONS ` •
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 ~ enewal 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.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete Fine 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.
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 13% 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
~''DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
~~.a... ,.e,
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
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 14 Y4, S T1_---/, N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CO//DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
;a Y f
Ell ( ) ❑ State Owned ❑ VILLAGE : ,
❑ Public El1 or 2 Fam. Dwelling-# of bedroom9~_(_ PAR LTAX NUMBER)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
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 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.E1 New 2.E] Replacement 3. ❑ Replacement of 4.0 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 El Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 Vault Privy
14 ❑ System-In-f=ill
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) f C ELEVATION
J C J~ y Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank 1 6,
Lift Pump Tank/Si hon Chamber G a ;y
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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
r
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTYIDE.PARTMENT USE ONLY
Disapproved Sanitary Permit Fee (includessg roeej water ate Issued Issuing Agent Signature (No Stamps)
❑ Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
I
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit 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.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, 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.
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 131/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawr to scale or with completo dimensions, location of
holding tank(s), septic tank(s) or other treatment tans; 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)
w
t ULBRICHT & ASSOCIATES CO. Op
_Reg. Designers of Engineering Systems
Private Sewage Consultants
655 O'Neil Road
HUDSON, WISCONSIN 54016 DATE 2 _ Z JOB NO.'
(715) 386-8185 ATTENTION
O RE: ~fi ~ •1 /DW 7 71& 5 6C,6
77
57-
S'y /05~
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items:
❑ Field drawings ❑ Reports Plans ❑ Specifications C(DPY
Y8py of letter ❑ Change order ❑
COPIES DATE NO. DESCRIPTION
2141 644 -944A1 3-D•t1
S• rn,f - f5 ~ D S~ avS
/0--A alle S eV
•o~_ Ov
Oe otf ceV A/5
L--
THESE ARE TRANSMITTED as checked below:
MI-or approval ❑ Approved as submitted ❑ Resubmit copies for approval
or your use n -Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS
L4-f 1<j
(yam
G~ S S D G.:v ~s .
COPY TO koo, SIGNED
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
February 24, 1994 201 East Washington Avenue
P. 0. Box 7969
Madison WI 53707
ULBRICHT & ASSOCIATES
ROBERT ULBRICHT
655 O'NEILL ROAD
HUDSON WI 54016
RE: PLAN S94-00329 REVISION TO PLAN S93-03096 FEE RECEIVED: 75.00
WOHLBERG, DAN REFUND DUE: 15.00
SW,NW,24,29,19W
TOWN OF HUDSON COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
An overpayment was made in the required fees and you will receive the refund
noted above in six to eight weeks.
SBO.6423 (R. 01/91)
SAFETY & BUILDINGS DIVISION
i
State of Wisconsin
Department of Industry, Labor and Human Relations
UIBRICHT & ASSOCIATES
Page 2
II
February 24, 1994
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above. j
Sincerely,
K nn th Stiemke
Plan Reviewer
Section of Private Sewage
(608) 266-8230 7:00 to 3:45 Mon. thu Fri
SBD-6423 (R. 01/91-)
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