HomeMy WebLinkAbout040-1112-70-200
C) I
O~
N A 060
a C C
N a O O
C is L O T
N
O ~ C Y
N oo
N
O S a
L N N
'S LL a
N
C C
O
(D
a`) ~p p N
O r L O 1 tlJ
9 Z N Z O
LL m L. m c~
LL C y O LL C
E ' c j'
3€ m€ o -0 O m
Q ao a Q y c
o~
N M
N
N
Z H
W Y O G
Z d d d d
co
am am
N H to
II O I
O Z d c
r 7 >
aUi Z a O G c Z
to I- ! c cu
,o m v E m I
N 7 N 3
fn d ~ y d ~
w y y N c
O
_ L
co
a - I
a
° O ° O `0
c a) Q z° VQ z z° °cn' z o
a
N z
= N
M d N d
co
! N N
C-4 16 0)
a O a Y w o CL O c o
rn y m N 4 4) CD > o o
G G a n y C G m n y N
m Z o
L Oa 0m m LL
a a a
go i > a~
a 1 >
N
0) ° °
fn J V rnr z
0
= O co cD_ 3 O E
O O 'O T O O p p 0
V m C V m y
m O Of N C
01V d Q Z f4 a Q (A m
(mil OV 7 a~
a+
1~ L C
o O Z a C c H C
O p M O 2 N C LL N N 0 U d°
co a a C o
O N O O C m N f6 C O O C N ~p
r co ~ O N O Oro N N N
E 4) -2 'D CD
a0+ L
FBI N O w 7 ~C.. co
o° o m m o 00 o mOE E v
°
• O N H O Z N 2 Z N O Z N
0 t
V~ Y a
daa y
.2 C
;
rr~~ o i`o
r- 2 ° p 3 'o
~1 A Ua2 0U) 0U)
` ,
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Hyman Relations INSPECTION REPORT ST. CROIX
Safaty iod Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Towin of: State Plan o.:
CERNOHAUS, FRANK
Insp. BM Elev.: BM Description: Parcel Tax No.:
CST BM Elev.:
I 7 A9400171
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss -1-Head
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
LEACHING Manufacturer:
SYSTEM TO P/ L BLDG WELL LAKE /STREAM
SETBACK
INFORMATION TypeO CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of =xxSeeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Troy.29.28.19W, SE, SE, County Trunk MM
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
co l
v'■■-■'■■~ In accord with ILHR 83.05, Wis. Adm. Code
IS -
STATE SAT #
-Attach complete plans (to the county copy only) for the system, on paper not less than (Q~ ~
8% x 11 inches in size. ❑ Check if revision toprevious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PRQPEFI+TY OW ER JJ PROPERTY LOCATION
1-w4 ~'lG7GGt-.1 %zZ t/a '/a, S.`Z T.&P , N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
G n/f
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Apt' VC r- j& //r vim- Z 3
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE
TOWN OF. 7?Z9
ELTAX NUMBER( )
❑ Public V1 1 or 2 Fam. Dwelling- # of bedrooms n PARC
III. BUILDING USE: (If building type is public, check all that apply) ! z D
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. Z 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 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/day/sq. ft.) (Min./inch) ELEVATION
00 D O &V Feet Z e 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
S is Tank or Holdin Tank
r
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sew/91 system shown on the attached plans.
Plu is Name (Print): Plumber's Signature: (N ps) MP-MPRSW No.: Business Phone Number:
2-f
P u '
g, k- s Address (Street, Ci , State, Zi C e):
o
IX. UNTY/DEPART ENT USE ONLY
❑ Disapproved Sa!V* ry Permit Fee (includes Groundwater ate Issued Issuing A m: Signa N mps
Surcharge Fee)
Approved El Owner Given Initial
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 maybe 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 counW-prior to installation.
5. 6nsite sewage systems must be properly rbaintained. 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 dode'adminstratorlor 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 in
II. Type of building being aerved.'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 al/
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 1]5 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.coilected through these surcharges are used for monitoring groundwater, ground-
Water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
x
n o
lip~
w
A
S
~ O
1 ~
N ~
"C P
,Z
W
l
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
FIEED Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM),
direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION Y DATE
OCATION
PRWTY OWNER: PROPERTY L
GOVT. LOT 1/4 1/4,S T N,R E (or~
PROPER OWNS': MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
17 y STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE 2f0 N I NEAREST ROAD
U6 a
[ ] New Construction Use VI Residential / Number of bedrooms 2 [ ] Addition to existing building
be
j Replacement ~ [ ] Public or mmercial descri
C" a de~edd daily y flow ~xrr gpo s~f Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft referred to site plan benchmark)
Additional design/ site considerations i crv+~i' tv c
Parent material t F odd plain elevation, if applicable ft
LU = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
fors stem El S El U ❑ S ❑ U ❑ S ❑ U ❑ S El U El S S ❑ U ❑ S ❑ U
= Unsuitable
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch
Z 7-31 91/1 d4 64)
Ground 3 ~ ~ ~ )k I
elev.
sc ! cod 02 .41 Depth to , = S I
limiting
factor f i6 i t V w ' _
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print F Phone: 7 y* - 3 GfG
X~f
Address: 26 .0z'&
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
• Jir'
Ground
elev.
ft.
Depth to
limiting
factor
Remarks: i
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92) r
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the (~4 ldezaez~ residence located at:
_1/4,_SI' 1/4, Sec.~9 TxgZ_N, R_,j W, Town of
Z~k z Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced_ 6,6"
Did flow back occur from absorption system? Yes No ✓(if no, skip
next line)
Approximate /volume or length of time: gallons minutes
Capacity: 447~ Construction: Prefab Concrete-Steel Other
Manufacurer (if known): yC,:V4
Age of Tank ( i n)
(Signature) ame) Please Print"
~ X89
(Title) (License Number)
(Da e
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. dm. Code (except for
inspection opening ove outlet baffle)
.E/
w,jjj2j&
Name Signature l• MP/MPRS•L9~
5/88 C 4z Z~/ 4)4 *1 ~
ST. CROIX COUNTY
r;
0WISCONSIN
ZONING OFFICE
t~,, ' v7 'r9t~~ 4
rx ST. CROIX COUNTY COURTHOUSE
tf _ 1101 Carmichael Road
fir Hudson, WI 54016
715/386-4680
EXISTING SEPTIC SYSTEM AFFIDAVIT
The existing septic system which serves the dwelling being added on
to must be inspected by a licensed soil tester for compliance with
high ground water and/or bedrock seperation requirements as set
forth in s. ILHR Chapter 83.10(2) WI. ADM. CODE. The results of
that inspection must be made available to this office. If the
existing septic system meets these minimum requirements, and is
,properly functioning, an addition may be added to the dwelling
without updating that system. This addition must not, however,
encroach upon the required septic system setbacks as setforth in s.
ILHR Chapter 83.10(1).
) / Property Owner (s) F-Mull K 4 L&
a l r I r~ C' ~C L
Property Mailing Address: cl~ UtL1,I)-F V
Property Legal Description: Lott CSM/Subdivision
114_~E 1/4, Sec.2f , T.Af N., R. ~ -W. , Tn. of
I, as the owner of the above described property, hereby a /firm that
the septic system serving this dwelling meets the above referenced
state private sewage system codes. I realize that this addition
may cause the existing septic system to become undersized for a
dwelling of the resulting size, and I will make this information
available to any future parties interested in purchasing this
property.
Notary Public
Subscribed and sworn to
before me on this date: V/ 1
1 rz Dui
Signed:.A.,*-, /0.
Date: 13 My commission expires:
Karen A. Karras
County Approval: Notary Date: State of Wisconsin
Commission Expires 218/98,
r
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER R ~~'t^uu ~1~ lae44,~
II
MAILING ADDRESS
PROPERTY ADDRESS ~'1g-lt~t
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 121 dl r
PROPERTY LOCATION 5~5 1/4, 1/4, Section T AS N-R1,'? W
TOWN OF d ST. CROIX COUNTY, WI
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.
FWe, 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: 4_~l
DATE: Cj)
St. Croix County Zoning Office
Government Center
1 i01 Carmichael Road
Hudson, WI 54016 11193
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property f{~kp ~.a`i~ZaG~
Location of property __,LE 1/4_ 1/4, Section,:~fTAX N-R /9' W
Township p Mailing address
Address of site y®•~.2-
Subdivision name Lot no.
Other homes on property? t/ Yes No
Previous owner of property
Total size of property "x;#l
Total size of parcel > 3 S
Date parcel was created
Are all corners and lot lines identifiable? I,"Yes No
Is this property being developed for (spec house) ? Yes t/ No
volume /044 and Page Number -5-f as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. 50,?y j;4 , and that I (we) presently
own the proposed site for 'the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signature of Applicant Co-Applicant
6 -f q t+
Date bf Signature Date of Signature
SPACE RESERVED FOR RECORDING DATA
THIS
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-198a
QUIT CLAIM DEED
• 4
' • 503436 j VOL 1026PAGE 54
- _ - 11--- _ REGISTER'S OFFICE II
j ST. CROIX CO., U
i~ ~
MARVIN E._CERN-------- OS and WANDA C. CERNOHOUS, Rec'dforReootd
Individually, s Trustees of the CERNOHOUS k AUG 19 j
•
•...EVOCABLE _TRUST....................................................
.
C RN HOUS at 8:30 - I
quit-claims to ......FMN..--Q•-----..----..-•.------•--••---•-- - _
WANWA"e
the following described real estate in ...••---_--._$~,....CrrQ1X-.............. County,
State of Wisconhin: :t RETURN TO .i
I,
I;
Tax Parcel No:
Southeast quarter (SE#) of Section Twenty-nine (29), Township Twenty-eight (28) it
i
North, Range Nineteen (19) West, St. Croix County, Wisconsin. ji
O O
rgAN5FE11
This homestead property.
(is) Mx4
Dated this st.... day of .....................4ujy..........--- 19--.93..
_~qO4 CI✓?~1~!----"(SEAL)- (SEAL)
. _Marvin__E.__Cernohous a anda C._ Cernohous...-- -
(SEAL) ..--------••--.(SEAL)
•
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF ynmo axt MINN
Ramsey County.
as-
authenticated this ........day of 19------ Personall y came before me this - 1st ••----day of
ill 19---93.. the above named
Marv ix~..E .---~erxtohous_. and-Jdaiada_.C............
Cerixohous> _.i.Lidi_Yi_dual.ly-.axLd_ as_-trustees
TITLE: MEMBER STeI''. a' BAR OF WISCONSIN
(If not, .
authorized by 706.06. Wis. Stats.) to me kno be the ons w ed the
forego stru wl s
THIS INSTRUMENT WAS DRAFTED BY
I!
HarQ1d..RA..FQt5c11A329X) , Haar d R. Fotsch
MOORE, COSTELLO & HART
Notary Public Ramsey County, )WAX MN
] ""MN 9r3~03' ' My Commission is permanent. (f not, state expiration
5 . E" Ch "St ma:ybe aut en'( 414r OY""St~icated " or ac "Pau; nowledged. Both
( gna ores
are not necessary.) date-
AA1tOlD N: Pi7T5tH
ZMLM 111 -IAglflDiA 9.-
RAA"E'r O~tMT1r
Wames of persons signing in any capacity should be typed or printed below their signatures.
ILC,tiihKCantpu+r STATE. BAR OF WISCONSIN
FORM Na. 3 - 1982 Stock No. 13003
Wisconsin Diparterent of Health and Social Services
• Pib. #V; 10/69 Division of Health
Z PERMIT APPLICATION l
for x/J
PRIVATE D(X,IESTIC SEWAGE SYSTEMS
A. OWNER OF PROPER 7 TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
County
B. LOCATION OF PROPERTY WH'RE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED
Check One: _
CITYI VILLAGE LE,AL DESCRIPTION:
Y_ TOWNSHIP
C. IS LOCAL PER1IT REQUIRED FOR THIS FDRK? ~ YES NO r L k? PE EIT NUMBER
D. SEPTIC TANK CAPACITY r:I Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NU ER OF TANKS TO BE I4STALLE°D: ~J7 1'
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence COmmeroial Industrial Other
(specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES' NO Automatic Potato Peeler YES NO
Other (Specify) _
G EFFLUENT DISPOSAL 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 Pit: Inside diameter Liquid Depth
P£ R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Dro in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnivht in Minutes Last Period Last Perio Period One Inch
Example
1
P- 0 3611 To Soil 1011, Clay 2611 25 es or no 30 1 2 1 2 2 60
IL
}
RZOORD DATA FROM. MINIMUM OF 3 TEST HOLES
ompute size of absorption are,, in accord with H 62.20 Wis. Adninistr tive Code.
_I
S O I L B 0 R I N G S- Minimum 36" Below Prooosad Absorption System
oring Total Depth Depth to Ground Water Depth to Bedrock -
umber Inches observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
- 0 72" 72" ^ Black To Soil 1211• Cla 18'1• Sand 1811• Gravel 2411
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
,y .
I ~
I, the ndarsigned, 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.
~~C~~"
NAME / ~L ( r't r>= f,f ' y✓ c" % ' TITLE
(Typo or Print)
REGISTRATION NO, or MASTER PL'vi"DER LICENSE No. rl ~~~J
ADDRESS
DATE .~/fj_~~Cr_ SIGMATU?F / ~I~ ~~~~!le'J/
t
MASTER PLI1163i;R MAKING APPLICATION
X MP
Signature: ~i ` i~ License Number: MP RSW
(To be Completed by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (dat } ! i Permit Number !/J>
Agent (name) For: Town, Village, City, ounty, 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 1 ~r(_ ACCEPTED BY RETURNED
' (Initials) (Date) See Corres.)
FEE RECEIVED VALID. NO. PER111T NO. 0.C C,
(Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS: