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HomeMy WebLinkAbout038-1061-70-300 Q c V I I o p ° p 6e. o M o 0 O N E E O O N N C H m O N C N E O L) U E Q m U a) CL N O_ Oi m O h O N ~ w N N_ N w T cn 69 3 -o p Z C Z E ° m ~6 L N LL N LL 2 c Q E Q) E Q U N m co N N Z O O L L Z r a m a co 0 76 o Z c c .U r 00 LO y O fA F- r m Y) a) Z c E c E -R "O N 'O m 2 Cl) 7 O N N ~ N N O U) cr W N Ul C d m fU N O EL M a O d O m O O O Q O Q Z (n Z Z H Z f~ I~ Z N r0 a C O N M U-) LO N _ E L _ m E N- N C Q L c w « 2 C c0 t0 .c d N C W d N 0 0 0 O O O a E Y O D G CL co N N Z M> v H H H m H H H N N EL m d Z O O •N ~aaa ~aaa a z z L) C) 0 m 0 U U O 0 0) 0) N Z N } N C0 O O M O O O f~ O **moil O N O O O O M 0) O w r E N N O T O U 44 (D LO r O U a u aNi Z Q > is Q LO a O o a LO ~ N_ O w N O w v O O C N N N N N ~J 3 C A C O 'O N C y s O *r O O 'D C E © M 0) I, O U N C O U C O 0) O a) c) O I u) 0 a) c CL C N N O ~p a0 C c m N C C N EO r0 N p O O N N •E O E O it O •O O M C L r ~1 r M CL C O O ( C O j O • 7~ co { O O C N m O p 0 C5 N Z O E CU/7 L O (4 O O - S Z N O O ~ w I, V d eo £a £a xx ° a w L: a w A 0 am 0 N 00 0 N 0 L J i i STC - 104 AS BUILT SANITARY SYSTEM REPORT c4. OWNER IA,IkX"Oh ADDRESS SUBDIVISION / CSM# ~i LOT # SECTION/15- T N-R W, Town of ST. CROIX COUNTY, WISCONSIN for, PLAN VIEW SHOW EVERY ING WITHIN 100 FEET OF SYSTEM i ~r r v i 340' 3✓`~ 7 3 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r f BENCHMARK: 90-:5<-_ ✓ We 5~- ALTERNATE BM: EP C TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: UGC /I s Liquid Capacity: 8~-D Setback from: Well House p03 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM r , Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: ~~2 l House, Other ELEVATIONS . e, .3 Building Sewer 7 ST Inlet. , .5 ST outlet ;Z PC inlet PC bottom Pump Off Header/Manifold - ? Bottom of system -~/~yf Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor an0oHyman Relations INSPECTION REPORT ST. CROIX Safgty and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 2 111 Permit Holder's Nam ❑ City ❑ Village Town of: State Plan o.: JOHNSON, MILTON & RUTH Q I star Prairie CST BM Elev.: Insp. BM ev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA o A9V TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S n Benchmark o;23' ,),Cai Do 'n9 ,y 3, 30 /d,3.93 Aeration Bldg. Sewer /do2,01 ding St/ W Inlet TANK SETBACK INFORMATION St/ Outlet 7 05-' Z- TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >j~ Cis ( ;)o /b4- NA Dt Bottom Do ' NA Header t i 4 1 , 00 Aeration A Dist. Pipe 971,91 Holdin Bot. System RZ 6V PUMP/ SIPHON INFORMATION Final Grade M u ac --Demand Model Number GP OSS TDH Lift Lnction Sys t forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches IT No. Of Pits Inside Dia. Li uid Depth DIMENSION DIMEN 1 SYSTEM TO P / L BLDG WELL LAKE /STREAM L G adurer: SETBACK INFORMATION Type O .v. ~ CHA er: System: -1 c s UNIT DISTRIBUTION SYSTEM Header/Manifold , Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length h Dia. Length 5S Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst my Depth Over „ Depth Over xx Depth Of ed Sodded ulched Bed/T~rcenter Bed/FrEdges 33 c2 Topsoil L;~ Yes ❑ No El Yes o COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: StarPra~irl4l,.15.31.18W,, NW, SW, ounty Road C Plan revision required? ❑ Yes B-146„ Use other side for additional information. 1// 1/0 6 s-- SBD-6710 (R 05/91) Date Inspector's Sign ture Cert. No. I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: s . i SANITARY PERMIT APPLICATION COUNTY ~ In accord with ILHR 83.05, Wis. Adm. Code STATESANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1 v 1 13 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 / MY4 RTYLOCATION S ,_-7-T , N, R E (or PROPER OWN R'S MAILING ADDRESS G- LOT # BLOCK # C-21 I CI STATE,/~~ ZIP CODE PHONE NUMBER SUBDIVISIO AME OR CSM NUMBER El CITY Lz Q r NEAF~ ROAD J 11. TYPE OF BUILDING: (Check one) State Owned VILLAGE • ~ GG ❑ Public M1 or 2 Fam. Dwelling-# of bedrooms AR EL TAX NUMBER(S) 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. P'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 ~Q REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ~ 6 77 vZ4eet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed -7 F-1 Septic Tank or Holdin Tank &le-elf-5 _f F-1 F1 El Lift Pump Tank/Si hon Chamber El El El Ej M F1 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe ' ame (Print): Plumber's ure: (No Stamp ^ MP/M`PRRSSW NNo/.:Business Phone Number: 0~ 1 PI s Address (Street, City, State, Zip Code): IX. COUNTYID-EPARTMENT USE ONLY ❑ Disapproved Sanita& Perm' Fee Includes Groundwater ate ssue issuing A tamps) 'harge Fee) / 41 Approved ❑ owner Given Initial (((~(JJJJ"`JJJ' Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) 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 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/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) PLOT PLAN PROJECT Milton Johnson ADDRESS 2125 Co. Rd. CC New Richmond Wi 54017 NW 1/4 SW 1/4S 18 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX ` 11/3/94 BEDROOM 3 MFRS BYRON BIRD JR. 3318 DATE 44- 1 CONVENTIONAL XXXX IN- UND PRESSURE CONVENTIONAL LIFT HOLDING TANK SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE MOUND HOLDING TANK SIZE LOAD RATE.7 ABSORPTION AREA 648 BED SIZE 18'X36' BENCHMARK V.R.P. Top of Tel. Ped Bracket ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL -H,R,P, Same as Benchmark VENT SYSTEM ELEVATION 97.20 12" GRADE TYPAR VR 2' 1 " 6' Q SEWER 12 Existing System to be Properly Abandond Bedroom ouse 10' c a n n 40' 43' Well 60' B- 40' -2 20' - - - I .M. 20' -3 Vent 40', 556' 640' Vnxuiq'yLjop4luiw""""""""y. SUIL ANU ,l l t tVALUA I IUN Mt1'UK 1 rage 1 of 3 taborand Human Relations Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix 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. 038-1061-70 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Milton V. & Ruth A. Johnson GOVT. LOT NW 1/4 SW 1/4,S15 T31 N,R 18 xf- (Or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # 2125 Co. Rd. #CC na na na' CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE (MOWN NEAREST ROAD New Richmond, WI. 54017 (715)246-3463 Star Prarie Co. Rd. #CC New Construction Use [x Residential / Number of bedrooms 3 Addition to existing building J4 Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 -8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximtmt design loading rate • _7 bed, gpd/ft2.8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 97.20 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem i ® S U ®S U ®S O U ®S o u S M1 S CK1 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure I GPD/ft in. Munsell Ou. Sz. Cont Color Texture Gr. Sz. Sh. Consistence BoLlrtdary Roots Bed tertdt 1 0-7 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 2 7-37 10yr5/4 none sil lfsbk mfr 9w if .2 .3 Ground 3 37-80 7.5yr4/6 none S Osg mvfr na na .7 .8 elev. 100.6 ft. Depth to limiting factor 80+" Remarks: Boring # 1 0-11 10yr2/2 none 1 2msbk mfr gw if .5 .6 2 2 11-26 10yr4/4 none sil lfsbk mfr gw if .2 .3 3 26-40 7.5yr4/6 none sl lmsbk mvfr 10 .4 .5 Ground elev. 4 0-88 7.5yr4/6 none is Osg na n . 7 1 .8 101.14 ft. ~ F_ A ~E a Depth to , limiting [ l f~ J factor +88" Remarks: CST Name:-Please Print Gary L. Steel Phone: 715-2 y Address: 1554 2 0th. Ave. , N w Richmond, WI. 54017 Signature: 10-2 Dat94 cstm 022 CST Number: _e_"Am~o - PROPERTY OWNER M. & R. Johnson SOIL DESCRIPTION REPORT Paget of 3 PARCELI.D.# 038-1061-70 I GPD/ft Boring Horizon Depth Dominant Color Mottles I Structure Bour iary Roots # in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bed iT a€ti 1 0-9 10 r2/2 none 1 2msbk mfr gw 2f .5 1.6 3 r> :mid 2 9-24 10yr4/4 none sil lfsbk mfr gw if .2 1.3 Ground 3 24-37 7.5yr4/6 none sl lmsbk mvfr gw na .4 1.5 elev. Os g na na .7 ; .8 100.70 ft, 4 37-84 7.5yr4/6 none S g Depth to limiting factor +84" I Remarks: Boring # NMI r Ground elev. ft. Depth to timitl ns factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. j ft. i Depth to limiting factor Remarks: SBD-8330(R.05/92) ~ w STEEL'S SOIL SERVICE Gary L. Steel Milton & Ruth Johnson 1554 200th Ave. CSTM2298 NW4SW4 S15-T31N-R18w New Richmond, WI 54017 MPRSW 3254 town of Star Prarie (715) 246-6200 1 N 1"=40' BM.= top of tel. ped. bracket at el. 100' I~Y~ta~C~`r ~.ry C7a ~ ya e~ N~ g-~ B-2 ~J `3 ard - -Dv" j G' X L-- 70 < 14 o,T /o p, Gary L. Steel 10-24-94 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER -lo h *1:5 0 K) MAILING ADDRESS g1,2 -5 & U -YI l c IRJ ( LC K I C ~'YI D 5k/ 7 ~I PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE [U ~.G a 2,o n PROPERTY LOCATION 1/4, '_::~,U) 1/4, Section ~s T_N-R~_W TOWN OF ~y"Gl.~ ~+cr. r ✓'t ' °c- ST. CROIX COUNTY, WI i SUBDIVISION LOT NUMBER 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: Zw &I DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, W1 54016 11/93 LUU This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. / Owner of property. Location of property Gl1114,5;a-,,9 1/4, Section , T.~,IN-Rl_&' W Township ct`- ~rrH~ M ilingaddress o?/~S G1~~~ CG Address of site huh-tom. Subdivision name Lot no. Other homes on property? Yes No 01 t Previous owner of property .t''n-C A" G crhlt"f l Total size of property !~;Z © 4Z Lr t5 Total size of parcel D e- 5 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes __Z No Volume bbl and Page Number cas 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 o ice of the County Register of Deeds as Document No. and that I (we) presently- own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. ~2:Sig atur of p icant Co-Applicant Date o Signature Date of Signature y Y3' N 240 W. V U,ed-To auwna .na Wit. u Joint Tm.n», Puelbnea by Eau Claire nooks euuonan co. 2'13 i - This Indenture made this 7th ~ day of February ,1964 between Bernice M. Covington and Bette L. Hartwick parties of the first part, and Milton V. Johnson and Ruth A. Johnson, i husband and wife, as joint tenants, parties of the second part. UAftiltgattb, That the said part ies -of the first part, for and in consideration of the sum of to them Dollars. I in hand paid by the said parties of the second part, the receipt whereof is. hereby confessed and acknowledged, ha ve given, granted, bargained, sold remised, released, aliened, conveyed and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate situated in the County of St. Croix Wiscopsin, to-wit: The North Half of the Southwest Quarter (N;; of SWO ; the Southeast Quarter of the Northeast Quarter (SF? of NFI); and that art of the North Half of the Southeast Quarter (N3 of SFf) which lies North of Apple River, subject to flowage rights of record, all in Section Fifteen (15) V Township Thirty-one (31) North, of Range Eighteen (1$j West. 1 This deed is given pursuant to Land Contract recorded on December 19, 1957 in Volume 345 of Heeds on pages 271 and 272, and assignment thereof recorded April 1, 1959 in Volume 356 of Deeds on page 269. d ~ 1R i~ r ~ I _ ' I i I' IL` i 'Cogttbtr, with all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said parties of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. , Co 1?abr anti to 1)o1b, the said premises as above described with the hereditaments and appurtenances, unto the said parties of the second part, as joint tenants. .Anti Me gaib, Bernice Me Covington and Bette L. Hartwick part ies of the first part, for themselves, their heirs, executors and administrators, do covenant, grant, bargain and agree to and with the said parties of the second part, and to and with the survivor of them, his or her heirs and assigns, that at the time of the ensealing and delivery of these presents they are well seized of the premises above described, 1I~ II II VOL PA E C ~ I c 0 y r, n y ~ \ C q• phi p ~1 I~p - to SC ~r o ' ti a 0. y~ ~7 CT: b ° m lb 6961 'BZ 2nV sa,ldx3 gopslwwoa ' Td3m . 1111110 r i_uo21azA (•tagou pu..anar r w - ~I `Aquno s.~+w..y~. `3dN mn•ro ...q ma ww.», w q ga..ur.ur m r.qr ..pr.n.a •+ne ~e~ ss va- a Ki -Ives IvTOTJ3o puvq Aw ges.oqunejaq 13oaaagM ssaugTM uj I u-Ea.zagg sesodsnd aqq Jo3 awns aqg pagnoaxa 0149 q 'pauTvguoo puv guawnJgsuT uTggTM aqq og pagTJOSgns aweu asogMuosaad~aqq eq ov V (uanoJd ATTJO4ov3sT4vs JO) uMOuH 'NDTMgJvH •I aggag paJvaddv AITvuOSZa04 d cggnd AJvgoN v 'aw aaojaq '1961 'AJvnagad 3o Avp -~3`--sTggup *SS XINROO N=illO do 31LVZS VOIN-11 .Ueion . 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I 7 ~G~3 Vd lop l0A 40 f{67 10/69 Wisconsin Department of Health and Social Services Plb Division of Health PERMIT APPLICATION for PRIVATE DOMESTIC SEWAGE SYSTEMS A. OWNER OF PROPERTY TYPE OR USE BLACK INK 1-21- Name Address (Street, City, Zip Code) r County B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXT ~1DED Check Ones ` 1/ CITY VILLAGE LEGAL DESCRIPTIONt +~~~C Ltd 6~ SYS A.-TOWNSHIP X/ 16- C. IS LOCAL PERMIT REQUIRED FOR THIS hORIt? -'YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALSs Prefab Concrete G Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLEDs E. TYPE OF OCCUPANCY /i/ G lid < ~~Dn1 Check Ones One or Two Family Residence Commercial Industrial Other Specify Number of Persons to be Accommodated Number of Bedrooms F. APPLIANCES, ETCs Food Waste Grinder YES 1 NO Automatio Clothes Washer YES !---N-0 Dishwasher YES NO Automatic Potato Peeler YES --NO Other (Specify) G. EFFLUENT'DISPCSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pits Inside diameter Liquid Depth 5 P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall lst Wetted Overni ht lin Minutes Last Period Last Period Period One Inch Example P- 0 36" To Soil 10" Clay 26" 25 es or no 30 1/2 1/2 1 2 60 RECORD DATA FROM MINIMUM OF 3 TEST HOLES omputs size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B 0 R I N G S- Minimum 36" Below Pro osed Absorption System _ oring total Depth Depth to Ground Water Depth to Bedrock Imber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches xsmple i - 0 72". 72" Black To Soil 12" C1a',18"• Sand 1811• Gravel 24" O-A •J 6 0 d Ifi b(s jr ' ' ' J tr G RECORD DATA FROM MINIMUM OF 3 BORE HOLES Is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3), _ Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. NAME TITLE q F ^ (Type or Print) REGISTRATION NO. or MASTER PLUMBER LICENSE No. ADDRESS f /i. d. G"-7-z_y,-4- J . DATE A L r - ~ /f SIGNATURE I MASTER PLUMBER MAKING APPLICATION MP 5 Signatures ILL, / 1/ t //~i~,._- > License Numbers MP RSW l- (To be C77 leted by Issuing Agent) Date of Application /C G Fee Paid $ Permit Issued (date Permit Number _ jD Agent (name) t~J!_t ./D, l!. Ct- Form//. C~L~iU l~t~~ Town, Village, City, County, etc. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY DATE RECEIVED ACCEPTED BY RETURNED (Initials) 42L~ (Date) (See Corr-s. FEE RECEIVED VALID. NO. Q -7 3rd PERMIT NO. Yes or No) REVIEWED BY APPROVED DATE (Initials) (Yes or No) .COMMENTS: