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HomeMy WebLinkAbout020-1283-90-000 ~ (i o o ~ p °es to a) C 0 0 4 a ti O o I N O v r I d I ~ I C I h a U c z ns E U. O ia c9 '0 cu <1 -0 I O V a) w z E o a z o N > a co N F- Z O O Z ! C w , Z d' O c o a, to F- m Z 1 c ~ -o ww ~ a~ ch I N ~ ~ I ~J u) 0 L = O C O N O - Z F- Z z N - w N CD E m (D (mil N O) y y c 00 1 a) L a) O p O 0 d 'O l O 4 N 0) 0 cr I. F- - E N NCI O O O IL~ Z° 1 •N a a a N a y cl, 0 0) 0) 0 cn -1 L) m 0) Z N ° rn eo = a E co co m c) :3 Q) (D IL t o N a~ c? -p N Q ~ in m ~i `t U) a w ►~11 0 o a c 0 N 0) O O O QI °i N C U CU O CO E E go 12. co o o -r c- 2 r-- LO N -O O • N O N ='i 2 O z N fn ID a t ° L: a y • L C1 a) .v a) y C r'MV y E 3 0 } ► z H Z) m ~ U D O D z ~ co z o D o z a cc _ z o cu m a ¢ -0 g D -0 a 7; z v w w w LL 7 W 1(~ u Q Z W p a a~ c E p v~i z ? =a R~ -mOa w Lil a ~ a F. 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I of 2- Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY ✓ DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE i.... ....................i..........»..........» i 4~ 1 l i E a j !1 .1 4 ? . . . . . : . .........i...........i .........>..........r.......... ................e..........i..........:........... e...........i-....................i w u . . : . . . . . . . : S f ioo - .............................4........_..... . s . . .........fr - d i... ....i-.. i . . 1 ..v--.......e U A . ~3 p 0 Q . ~T _ t . g ? . I :031 i . /~~i... "-A PRODUCT 205-11~liic., 310m, Mass 01471. To Orft PROBE TOLL FREE 1-M225-M JOB •LJ~//~J4~oGIJL°G/ ~r TIMM EXCAVATING SHEET NO. OF ~ Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY `"OJ1TE- ~~/2--~J (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ..................1.......... a . . > - r. n . > 14.0 . 1a3~9u daJ ~.tp ` -ve ,(j o T _l t . ! . . O - ( 6 d....... . . ' . _ PRODUCT 205S11~Inc-. Groton, Alms. 01471. To Order PHONE TOLL FREE 1-800-225G180 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 361'(1/.// ADDRESS 5«~ 1~r&4 d s4/adulw /".k SUBDIVISION / CSM# LOT # 11f SECTION ad T =)9 N-R //r W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM `;zv ~ + • c x rs well IA-e i 85 a {e4 92 ai tyl INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form- Provide 2 dimensions to center of septic tank manhole cover. F t I BENCHMARK: . ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: j,/,C1c.r Liquid Capacity: Setback from: Well House Other Pump: Manufacturer A114 Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: S Length S Number of trenches a Distance & Direction to nearest prop. line: Setback from: well: k5' 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: -yam PLUMBER ON JOB: LICENSE NUMBER: ?2 2 INSPECTOR: 3/93:jt ~,~i far ~ i lds - 29.19 L IF I~ME SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safetyvand Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) SanitargrrniOOIN Permit Holder's Name: ❑ City ❑ Village k Town of: State POMP Insp. BM Elev.: BM Description: Parcel Tax No.: ~ , TANK INFORMATION ELEVATION DATA A9300244 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ( 5 art f' Benchmark Septic Dosing- Ll FH ra tion Bldg. Sewer ldin St/,01 Inlet TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake /7 ,4 NA Dt Bottom Septic >5Q/ Do ' NA Headerfhbjg. o4 Aeration A Dist. Pipe Bot. System Holdin 91 PUMP/ SIPHON INFORMATION Final Grade S Soi" to dg u Demand Model Number GPM -720' Gu~. cr_etfzr~G1,_ TDH Lift L ton System T r-E Forcemain Length Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM Liquid Depth BED /TRENCH width Length No. Of Trenches PIT No. Of Pits *Ins,dD,a DIMENSIONS 7 DIMEN I J'L BLDG WELL LAKE / STREAM SETBACK SYSTEM TO P/ LEA ie' CHAMBER INFORMATION Type 0 4 System: {.ranr,.Qv OR DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) , x ole Size x Hole Spacing Vent To Air Intake Length 4~2 i Dia. Length v Dia. Spacing , SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Syst I Depth Over Depth Over „ xx Depth Of xx Seed odcled xx Mulched No Bed /Trench Center K Bed/ Trench Edges 30 - Topsoil Yes ❑ No E] Yes F-1 COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION : HUD ON .20.29 .1 L C c2 e:'~ Plan revision required? ❑ Yes No V / RI / M Use other side for additional information. 16 SBD-6710 (R 05/91) Date Inspector's Signat re Cert. No. r ADDITIONAL COMMENTS AND SKETCH - SANITARY PERMIT NUMBER: JOB rule r~ TIMM EXCAVATING SHEET NO. I OF 2- Route 1 Box 192 _ WILSON, WISCONSIN 54027 CALCULATED BY'"" DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE A............................. . j`CYfs b ! 7 : . . L y i as -~7.. r - . ..O ...t ; :...i.~jb'~~~ i _ - - =--1 rt6 ~z ri1 'i o o ran t . ,i t i., Lof ~orrler 160 I PRODUCT 205-1 1 nc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800.225-6380 JOB •U~j ~~G[lt°~~ TIMM EXCAVATING SHEET NO. OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY 4ATE iF- A~ (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE I # j 044 UP ✓ L! _ . [ !a3 9v . . r _ _ r, . U s,~ r L - . PRODUCT 205-1 Inc., Groton, Mau. 81471. To Order PHONE TOLL FREE 1-800-225-6388 0ILHR SANITARY PERMIT APPLICATION • COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITAR PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than Y, 8% x 11 inches in size. ❑ CI(eck If re1ston to 4"_ 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 N, R ~r E (or r. PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r- -gyp II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE ❑ Public 10 1 or 2 Fam. Dwelling-# of bedrooms PAR ELTAX NUMBER( Ill. BUILDING USE: (If building type is public, check all that apply) _ r> 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. El New 2.0 Replacement 3.E1 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 Q 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) Feet ELEV 10 et f A 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 FJ 1=FR4 =E1 1:1 El Lift Pump Tank/Siphon 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: (No Stamps) MP/ PRSW No.: Business Phone Number: l ✓ 7° r -1'3- f I i, /:,E•y f ✓ ..p.t._..._.._... r. d r f P .y' f - 1 /,a Plumber's Address (Street, City, State, Zip Code): - f C/ Wit; s 'y'. /J Z~ IX. COUNTYIDEPARTME USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a gsue Issuing Agent Sig9a [a (Ncy stamps) Surcharge Fee) ❑ Approved ❑ Owner Given Initial 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. f 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 po)nta 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 VE 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. ❑ c(,eck if r~islon tdprb,dous 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 i '/e, S T,c fB N , R E (Oryi OPERTY OWNER'S MAILING ADDRESS LOT # LOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ VILLAGE : - ❑ Publlc ®1 or 2 Fam. Dwelling-# of bedrooms c_ PARCEL TAX NUMB R( ) 111. BUILDING USE: (If building type is public, check all that apply) " 67 1 El 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 4.0 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 0. 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.) (Gal day/sq. ft.) (Min./inch) 9~ 1 /d ELEVATION Feet 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 Se tic Tank or Holdin Tank I El F] Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/ PRSW No.: Business Phone Number: / r i f~r sf /e r~C,r //i~.,Fi 1. ; ~'f~ _ ~.Y - ::r - 17 2171 Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater EDate ssue ssungenignature (N, tamps) Approved ❑ Owner Given Initial urcharge ee Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber Y 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 approvfd 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. ll. 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 n ains/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) =1t SANITARY PERMIT APPLICATION . COUNTY a In accord with ILHR 83.05, Wis. Adm. Code A SANJ~I -AAY P plete plans (to the county copy only) for the system, on paper not less than -Attach com $'/z x 11 inches in size. ❑ CM1eck_{f re is on r ous 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 .4W'/4//OrY4,S o'j b? N R l~ E(or A, OPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # e-,.-oVj a& A.1s..v W /9 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1 9%5' *11;111eZ_1 A71 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State owned VILLAGE ; .a~[so•d ~°~T/ row, ❑ Public W 1 or 2 Fam. Dwelling-# of bedrooms 5 AR x N M III. BUILDING USE: (If building type is public, check all that apply) ~2 0- ~3 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.E] 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 El Seepage Bed 21 El Mound 30 El Specify Type 410 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. 17. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals day/sq. ft.) (Min./inch) Q ~Tl6s v ELEVA ION ~li r7~ /l~Gly 778 Feet /G/s4 Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in gallons Total # of Manufacturer's Name Con- Steel glass Plastic App INFORMATION New Existing Gallons Tanks Concrete structed Tanks Tanks Septic Tank or Holdin Tank e s LJl ST Lift Pum Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: ( o stamps) / PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): Id 57,0 ff Q,o , . SyXVZ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e lyb_ued Issuing Agent Si tamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) 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 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) A c7" l ! 4 G✓• `G/c~v ✓'e .'d ~B> ~s 07 1 IA/ ~ r Ed~J~ pF U; r Ta R oC ihiN f= r , ! s, e d Q L llux eat/ I W,tsconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page f of $ Labor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code • COU.~NqY )a 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 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 GOVT. LOT h j W 1/4 r(LC 1/4,S'7-6T "Z9 N,R J 9 E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT BLOCK # SUBD. NAME OR C # Lj IL.i.03.✓ t+~'r..C ii Jarl, CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD ) New Construction Use [R~ Residential / Number of bedrooms [ j Addition to existing building j j Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate ©.7 bed, gpd/112 S trench, gpd/ft2 Absorption area required 645; bed, ft2 -t615 trench, ft122 - Maximum design loading rate 6.-? bed, gpd/ft2 (I'S trench, gpd/ft2 Recommended infiltration surface elevation(s) No-, 4'L 10 fo NAw J KA _ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system o VENTIONAL MOUND IN- ROUND PRESSURE AT-GRADE S TEM IN FILL HOLDING~K IV ~ suitable fors stem ® S El U WS ❑ U [ S❑ U S❑ U S❑ U El S S U U= Unsu SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tretlt:tl -77 3-15 101YA 5-9 16ykd~ ell C Ground 10 4- S l 4' 7 d T L) elev. i01. a6 ft. Depth to limiting factor ~ yob Remarks: Boring # rY Z Q•4 0,~ r, Cr M j 0.4:0. ^1Z 4. Ground 1 4 elev. lout. Depth to limiting ~ f~ctgr7 Remarks: AQ~O CST Name:-Please Print Phone: 6 y a ~ rvsd~ I 7 Address: , 0. 1 cJ Sc~~1 W i S40 1 I, Signature: Date: n CST Number:., G+ PROPEMCWNER SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.4 Lill W , LL©W T.id4K l~4S i Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench € « ` 0-/D /o-,lp v / L J -s ~K rk, vi 4 z 0,416,151 /6-/9 6A 65- Ground A, i Q .7 Q. el v. J+. Depth to limiting factor Remarks: Boring # KUM Ground::: 6 Z 0-!Z j ,tG elev. io44 %ft. Depth to limiting factor Remarks: Boring # /oYte 3 L, i sbK rs, 2 p .4 o.~ rh-yy- 1QYP, 44 S r h, 1 1 a, Ground elev. haNft. 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