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HomeMy WebLinkAbout020-1122-90-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Sue l~ ADDRESS i r SUBDIVISION / CSM# ~n LOT # I SECTION, T N-R ; W, Town of N!J 0 /~I ST. CROIX COUNTY, WISCONSIN 4( PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Coo w . _ 9' Ig' a y ; /opd y ~J U I I F,'J FJ /r~ Va Ive 111 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: Liquid Capacity: ~U Setback from: Well House ~~3 - Other Pump: Manufacturer Si e Float satio~n~G a l o e: Alarm OIL ABSORPTION SYSTEM -;S Width: D Length J Number of trenFhes Distance & Direction to nearest prop. line: Setback from: well: ) House c) Other ELEVATIONS i u' lding Sewer ST Inlet; ST outlet 1.30 PC inlet PC bottom Pump a " 94.d`1 gy 'R6ader/Manifold Bottom of system /3 5 Existing Grade 9755' Final grade 7 5S 9141) ~\Ar„ VA)vQ DATE OF INSTALLATION: ) PLUMBER ON JOB: QQ+,~~ LICENSE NUMBER: e W 9 T, ~ (p L) INSPECTOR: 3/93:jt LQWA • rtHUW Nus 7.29.19.5`~R It~~IWG$TEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitar g,rt OIX GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI PASNIFUG X lev.: Insp. BM Elev.: BM DescriptiorWJ Parcel Tax No.: da _ _ 3 TANK INFORMATION ELEVATION DATA 206 ~ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ex w, Benchmark SZ: logi- & Do g . 30 Q?-9J Aeration Bldg. Sewer Holding St/ Inlet TANK SETBACK INFORMATION St/ t Outlet .ZZ W.30~ TANK TO P/L WELL BLDG_ Ventto Air Intake ROAD Dt Inlet 01 a tZA Septic SSOt >50 NA Dt Bottom Dosi NA Header.4 MaAr L Z,16 99. SC2 f Aeration A Dist. Pipe 1Z. Z46 01 yS! aG Holding Bot. System 3xo( 91 PUMP/ SIPHON INFORMATION ' G a e j7 74, Ma urer Demand Qo7.07~ Model Number GPM TDH Lift Friction m TDH Ft oss Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 8 Length No. Of Tr riches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION 5-40 DIMEN 1 N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA G Manu actu SETBACK CHAMBE INFORMATION Type O o e Number: System: don I*. >/10'_ " OR UNIT DISTRIBUTION SYSTEM Header rMartifviE 4 Distribution Pipe(s) eI x Hole Size x Hole Spacing Vent To Air Intake Length ~ pia. ~ Length ~ Dia. YC Spacing S~ 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 / Treweh Center ' Bed / Lwaeh Edges Topsoil ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 07.~9.1G9.546 (KRATTLEY LANE) I Plan revision required? ❑ Yes o Use other side for additional information. O SBD-6710 (R 05/91) ~ S Date Inspector's Signatu Cert. No. SANITARY PERMIT APPLICATION - - DILH14 In accord with ILHR 83.05, Wis. Adm. Code COUNTY IS1 0', X .,..,..,,~,.a. # STATES ITAZY~T -Attach co mplete plans (to the county copy only) for the system, on paper not less than ❑ cfi 8% x 11 inches in size. ec iev vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY WNER PROPERTY LOCATION (t 'a.,S£ S ( T , N, R E'(or) W LOT # BLOCK # PROPER' QWNER'S MAJLING A D SS ~A~e j~3 7 R CIJXY, STATE ZIP C 06E PHONE NU BER SUBDIVt NAME OR CSM N BE SoU 1►J'IsC. 1 5514 dl I PR OF: EJ CITY _J -,14 II. TYPE OF BUILDING: (Check one) 1:1 State Owned I >j ❑ Public **N 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) OaO U 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. El 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 [9 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 REOIg (sq. ft.) PRO SED (sq. ft.) (Gals/day/sq. ft.) (Mt /inch) *ELEVATION ~"sV~~ - 7 Feet 1 • SFeet VIL TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. Con- INFORMATION New isttn G~[Ions Tanks Manufacturer's Name oncrete st ucted Steel glass Plastic App Tanks anks Septic Tank or Holdin Tank __+\Jqb I NE!~IlLd I P _Q F1 I p 11 1 Ll Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu is Signatur (No Stamps) MP/MPRSW No.: Business Phone Number: r., Q't 11 3 0 l5 a K oa Plumber' A dress (Street, City, St e,TZip de) 1l 6% M1 Z1~ s,6 - t , -Ps )j s o IX. LINTY/DEPARTMENT USE ONLY ❑ Disapproved S!1 ary Permit Fee (includes Groundwater Date Issued Issuing Ag t Sign No St ps Approved ❑ Owner Given Initial / Surcharge Fee) Q' Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & 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 P4mped 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 Divi§ion, 608-266-3815. To be complete and accurate this ganitaryrmit application must include: I. Property owner's name anti (nailing address. Provide the legal description and parcel tax number(s) of where the system Is to bpjnst4I(ed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. 111. 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; yells; 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. l The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) P. ? B- L, 7 _ f ~ L. OTA ► C I 0 SS S f ~ C ~I I Itl_ P R 0J l_Crl_ - .._~j 1 N A M E SkA,~ g~ _ ..N ..A 13 L a C ANN K A l ~ ~ L I C ENS E-= . Sysfi~,V 100 NO p S z • 45 N4, 7 _ Upl~~a ,3 r 14 FRESH All! INLETS AND OBSERVA'PgON PIPE C►2nSS SECTION - Approved Vent Cap ~~~1 Minimum '12" Above Final Grasie~__~._ TIN" I i , A" Cast Iron Above Pipe Vent Pipe To Final Gracie Marsh Hay Or ~Synthetic Coveri. ng Min. 2" Aggr.c(AM, 1 Over Pipe Distribul•.ion Tee I Pipe Aggregate v_ Per•f.orat:ed Pipe Delow fib' or. I)encath Pipe \ ----Coup).ing Terminating' A ~ ~'3- S Bottom of System Laion Department ofindustry, Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page of , Division of Safety rf< 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 OWN PROPERTY LOCATION GOVT. LOT N f 1/4 Sf 1/4,S T ~C N,R -5 e- dcva PROP TY OWNER':S LING ADDRESS LQ BLOQ I SUED. NAM 0 PM # [.AAI /!J i t i CITY TAT ZIP CODE PHONE NUMBER OCITY VILLAGE OW NEARE%OAD ] New Construction Use W Residential /Number of bedrooms [ ] Addition to wdsting building Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate-, 5 bed, gpd(ft2 , trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _,_,_77_ped, gpd/ft2 ,_trench, gpolft2 Recommended infiltration surface elevation(s) 2 ft (as referred to site pla nchmark) Additional design / site considera'o s S r , j Parent material lilt A~ „ Cvey V" ~z I plain elevation, If applicable It C S = Suitable for system CONVENTIONAL MOUND IC~II-GROU PRESSURE T-GRADE SYSTEM W~II FILL HOLDING TANK U- Unsuitable fors stem ❑ U S❑ U S ❑ U S❑ U ❑ S 1 11 11 S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft . Consistence Bmrd3y in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch R"- 4M, 701777- A F . ~ 3 Ground Y . V g- S r2 4-3 AID.- S / ~ S ti,(C m vr~ C t,, y S Depth to ~~t limiting Remarks: Boring # Ground yy Z -3 77, 7 SYS` Ors s 9 0.710- Depth to limiting >factr Remarks: CST Nam le a Prin Phone: ~ Y3i Addres : Sign Date: / CST Number: V~Lr I IVI\ nCrvnI Page,Lvf ~J PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft in. Munsell Qu. Si.-Cont. Color Consistence Bouxiary Roots Gr. Sz. Sh. Bed Trench Ground 3 Z_ -7L' v l 7 B' Depth to limiting factor /.1 Remarks: Boring # r~ r Ground elev. ft. Depth to limiting factor . . I t Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: .Boring # S Ground elev. ft. ' Depth to limiting factor Remarks: SOD-8330(R.05/92) P~ o't f v -~-a n 8Z t v i ^y1 N N i A ON 7 T219Nq R , TOWN of HUDSON ST C 4 f / SyF #2° I V ~h lc ° N 87°0840"E 440.18 2 41.58 58.35 //g° 68' 340.25 45° 99.93: O -1 C) Dos 30 ~ .ov3, ~ ~ r I.OI ACRES N I6 3.00 , ca p . W 3 1.22 ACRES 2 10 - X66°29.10 N h 0 4?0 co 47-, N t 1 `=r °3T'~z ° h 1.59 ACRES±n 9 7.19' O khf4:8 46 o 0 2 mot. I N66 ~3 85 ~ti~ n' 1.39 ACRES 32°10 99°04 55 L 1 3~\ t , N6 ~,L I s 13 ti o o 14 , 1.97 ACRES 2v'~ 89°41'05 i ' 1.82 : RES ;.,5 0 Q ~ I ~ 455.24 1.80 ACRES (9~ I 324 , 1 ~ •s 12 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 5~~ IJRU{J~ residence located at: N L ' \1/4, -S 1/4, Sec.T 0 N, RA 10 Town of t~LtDSO1J Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Q Last time serviced ~uq ~ Did flow back occur from absorption system? Yes No if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete _steel Other Manufacurer (if known): Age of Tank (if known): ~a ~t„~ o o ~ i rY, 1~ a U rn .s 1-Q R (Sign ure) (Name) Please Print 14 3YOV (Title) (License Number) 9 (Date) 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. Adm. Code (except for inspection opening over outlet baffle). ~J Name-Tim PodtAMjzAzfi~K Signatureg:~~ &wmo6-,,MP/MPRS 3 7U 5/88 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County a n OWNER/BUYER !5~esQ r7 ie ADDRESS: ~ 7 -,tlgle g - h4re k on FIRE NO: &f 7 LOCATION: 1/41 1/4, SEC.___z7_T f 9 N-R 19 W, TOWN OF: T~uc~SD /1 ST. CROIX COUNTY SUBDIVISION: Er LOT NO. 17 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 a 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. rro;x County residents may be eligible to receive a grant to ,,aip with the cost of the 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 the St. Croix County zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately. 30 darts prior to three year expiration. !/WE, tii~ undersigned have read the above requirements and agree to maintain the,-.!, Private sewage disposal system-in accordance with the standc° rds set forth, herein, as set by the Wisconsin DNR. Cert-i.fica.t:_on form must be completed and returned to the St. t;z:oix `..'ouit-T ?oning Officer within 30 days of the three year A" SIGNED: DATE°_ 93 St. Croix County Zoning Office 911 1 th St:. Hudson, l 54016 - + AS BUILT SANITARY SYSTEM REPORT C)15 OWNER 5 a M / 1, 1 1 e r TOWNSHIP ! ohs o SEC. 7 T,:7*-R/qW ADDRESS f o u & e ~C ST. CROIX COUNTY, WISCONSIN. ty 'C4 d S Q <l w1 t S SUBDIVISION ,r y Cr r" r LOT /7 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 lnl_ EVERYTHING WITHIN 100 FEET OF SYSTEM 4-7- CIO i I di ate or,thi A rnw qCALk: BENCHMARK: (Permanent reference Point) Describe: T Elevation of vertical reference point: cG Slope at site: j 2!.6 7e Wro~~^ SEPTIC TANK: Manufacturer : -o--• rc Liquid Capacity: 1,0410 Number of rings on cover : _I Tank manhole cover elevation: q 9 Tank Inlet Elevation: 1&1 Tank Outlet Elevation: 0! C If PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle gallons; tota capacity o distribution lines gallon: size of pump head; gallon per minute horsepower brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: um er o pits feet diameter feet liquid dept seepage pit in e-t pipe-elevation bottom of seepage pit elevation feet. Etile depth SEEPAGE BED SIZE: number of lines width _ _length - SEEPAGE TRENCH: width length PERCOLATION RATE 2 A REQUIRED 72- _ RE AS BUILT INSPECTOR DATED ~ lar~5 I~ PLUMBER 0 JOB LICENSE NUMBER ~ /~Z 17 Fallet y e --ft n t r~,l( iA' vm i Aol,v s d le. Co., t L th"'~~_ S ~0~4 c DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR''At HUMAN R~LATIONS PRIVATE SEWAGE SYSTEMS DIVISION B.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number. (If assigned) D Holding Tank O In-Ground Pressure ❑ Mound NAYOF RMIT HOLD R: r JADDRESS OF RMIT H DER: INSPECTION DATE: ,/D aZt.s z BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:. REF. PT. ELEV.: CST F. PT. ELEV.: lelga) 17 e!)Ao' 7, Name of P tuber: MP/ PRSW No.: court. , Isenitary Permit Number: SEPTIC TA /HOLDING TANK: MANUFACTU E : • LIQUID CAPACITY: TANK INLET ELEV.: a TANK OUTLET EL V.: WARNING L BEL LOCKING COVER 0 Z PROVIDED: PROVIDED: J/ ,t~•/~ OYE~S ❑ND DYES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH W NUMBER OF ROAD: ROPERTY WELL BUILDING: V NT TO FR H At LET: I f( ~f ^ Q ALARM: FEET FROM / I LINE* _ + 91YES DNO /(2 0/ ( DYES DNO NEAREST N V"1 U DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES DNO DYES DNO DYES DNO. GALLONS PER CYCLE: PUM AN CONfR_MS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: V N FRE (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) DYES DNO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH [IAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN C NVENTIONAL SYSTEM: WIDTH: LENGTH: N DISTR. PIPE SPACING. INSIDE DIA. Ot PITS. L OUtD BED/TRENCH ~/t~ TRENC 4. If T PIT DEPTH DIMENSIONS UAT'VEL DEPTH FILL DEPTH JDISTR. I F DISTR PIPE IS 1 rERIAL: NO. DISTR. NU BE OF RTY WELL: BUILDING: VENT TO FRESH BELOW PIPE ABUVE COVER: ELE . yJj~J ELEV~ _ J PIPES - FEET FROM LINE: AIR INLET: f~/ U NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO OIL COVER TEXTURE: PERMANENT MARK S: OBSERVATION WELLS DYES DNO DYES DNO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED. SEEDED: MULCHED'. CENTER: EDGES: DYES ONO DYES ONO .DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH. TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL . JNO.DISTR DIS R. 1 DISTHIBUT ION PIPE MATERIAL & MARKING ELEVATION AND ELEV. ELEV.. DIA. ELEV.. PIPES DA. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECILY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DY DNO OYES ONO COMMENTS: PERMANENT OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES CI NO DYES El NO NEAREST Sketch System on Re ' in county file for audit. Reverse Side. SI TU I DILHR SBD 6710 (R. 01/82) State and County State Permit # .PL B, 6 7 1 Permit Application County Permit # h for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. 5alIx OWNER ~(O/~F PROPERTY Mailintg~ Address: lf4 B. LOCATION: % Section T2qN, R (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# ` Village Township .j(&dsoorl 'a y~A /Q, d~G A C. TYPE OF OCCUP Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY 1060 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete-ter- Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT ,DISPOSAL SYSTEM: Percolation Rate Total Absorb Area 772- sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top)-No. of Trenches Seepage Bed: L" Length Width 19" Depth 42 Tile depth (top) 3 2•~ No. of Lines Seepage Pit: Inside dip4npter Liquid Depth No. of Seepage Pits Percent slope of land-. S s G T °s~~ Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester NAME AA A(S Gti 5 d h~h`fP~l C.S.T. # 7 ? and other information obtained from p r (owner/bu~ Plumber's Signature MP/MPRSW# /NF ' 13' Phone #,;21-7- 3 / 2 3 Plumber's Address k- & W~ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. , 3 , , i 1 V _ s a P_ i E Do Not Write in pace Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Applicat' n Fees Paid: State County Date Permit Issued/Re cted (date) Issuing Agent Name Inspection Yes State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVIS F HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) Revised Date 7/1/78 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDGeT.RY, DIVISION LABOR AND - PERCOLATION TESTS (115) MADISOP.O. BOX 7 N WI 5370 MUMAN RELATIONS LOCATION: SECTION: 0 ~WkNp~l P SAALIdLLGF?r~1TY. LOT NO.:BLK. NO.: SU DIVISIO NAME: 17 JE 7 1Td7N1R17#(o& COUNTY: OWNER'S BUYER'S NAME: M-AyIILIN ADDRESS: USE DATES OBSERV IONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: S: PERCZ5LATION TESTS: Residence 10 New ❑Replace ~SO(,- 4'U7 ,E.7- RATING: S= Site suitable for system U= Site unsuitable for system # Oi¢ CONVENTIONAL: IN UND•PR URE: Y MOUND: GRO ESS ~S S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: o tional Ip ) ❑U [MS ❑u CAS ❑u ❑S ©U ❑S u If Percolation Tests are NOT required DESIGN RATE: SYSTEM ELEV. If any portion of the lot is in the under s.H63.09(5)(b), indicate: N ~1/ I Floodplain, indicate Floodplain elevation: W/~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED E . IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.nON BACK.) B- !Q H p /K~iZLL `Q ~r tr An ~r AS B- 2 771-011 > S' y 6"AIM 6 S, / B- 3 aAZ y r / ,LS Oct / sr S 01 B- 30 "AA y6 .9.47 s/-« B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 PERIOD PER INCH P_ A& 340 13 o2 O P- Z 3o8r 3 o s a2 - Z / Z P_ Yd „ 3 0 .2 .2- P-. P_ -T- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of a soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the p1 SIII t urface elevation at all borings and the direction and percent of land sloe. SYSTEM ELEVATION Q P CS r~ -r Y_ 0, A,44,0,.. hi A `0 • J~• Gj /j C k u ..._e--. ..._m.. ._...r..._`z,e .6. .,ate...... ,.e_.. AA,.~ the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ~ay ` . 6 -,27 9;'- - ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): L ~ S v ~s 7- / S-~3 CST TUBE: r DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) J s ~ Y M~ v C N 0 J S e"` c h K c ~C c ZVI Y Qq t Q L C J