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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 08/15/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner 0 - JOHNSON, DENNIS A & JANICE DENNIS A & JANICE JOHNSON 1448 210TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1441 210TH AVE SC 3962 SCH DIST NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 3.080 Plat: 5247-CSM 21-5247 036-2006 SEC 19 T31N R1 7W PT NE NW CSM 21-5247 Block/Condo Bldg: LOT 01 LOT 1 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 19-31N-17W NE NW Notes: Parcel History: Date Doc # Vol/Page Type 04/18/2012 954653 EZ-U 03/08/2007 846105 QC 07/25/2006 830483 CSM 05/24/1966 284485 423/410 WD 2012 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/28/2011 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.080 35,400 119,400 154,800 NO Totals for 2012: General Property 3.080 35,400 119,400 154,800 Woodland 0.000 0 0 Totals for 2011: General Property 3.080 35,400 119,400 154,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 y • AS BUILT SANITARY SYSTEM REPORT - NER - S '_-1:41 oL-0, r TOWNSHIP_54t. 4' SEC. T N, RAW ,0. ADDRESS t, C 3 , ST. CROIX COUNTY, WISCONSIN. . BDIVISION LOT LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM #0 k5E ~ - UHF l~ 3 ; C)i ?TIC TANK(S) MFdR'~45-CONCRETE STEEL NO. of rings on cover Depth DRY WELL -NCHES NO. of width length area D no. of lines -z width-/o, length .S z area C yr ' depth to top of pipe__-,? -z '1RF.GATE ° 0 c-f. :?K RATE AREA REQUIRED AREA AS BUILT G~ sciaimert The inspection of this system by St. Croix County does not imply complete -pliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for Stem operation. However, if failure is noted the County will make every effort to zermine cause of failure. BASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. ' / 'INSPECTOR / - DATED~Il~ PLUMBER ON JOB T• LICENSE NUMBER l' • REPORT OF IIISPECTIO?I--INDIVIDUAL SE-14AGE DISPOSAL SYSTEM Sanitary Permit .317 r ; State Septic /d-07 .,A.IE T&INSHIP • t. Croi;_ County SKPTIC TANK Size gallons. `)umber of Compartments Distance From: Well . f t. 12% or greater slope Building* ft. Wetlands f Itighwater ft. DISPOSAL SYSTE:2 Tile Field or Seepage Pit(s) Distance From: i1ell L ft. 12%.or greater slope £t Building ft. Wetlands f FIELD Hifhwater ft. Total length of lines _ ft. Humber of lines Length of r . each line 4► ft. Distance between lines - ft. Width of the trench ft. Total absorption area sq. ft. Depth of rock below tile Z: in. DP-pth of rock over tile in.. Cover _ Dver.rock., a c. Depth of tile below grade in. Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS . Humber of pits Mks' a" 'ameter ft. Depth below inlet ft. Gravel aro"~. t: `yes no. Total absorption area sq. ft. Square feet of seepage ~_rerich bottom area required Cquare feet o e° seepa :e t area required Inspected Title' _~4!,ly Approved Date 197 Rejected Date 197 State and County State Permit # PLB67 Permit Application County Permit for Private Domestic Sewage Systems County F~'~f X *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: ti s n/tS o . ~3 , t m~-rv d . B. LOCATION: Y4 f*t,) Y4, Section TEL N, R (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher I/ YES NO Food Waste Grinder-YES '-'ISO # of Bathrooms Automatic Washer V YES NO Other (specify) E. SEPTIC TANK CAPACITY Total 49all~oonVn~ No. of tanks *Holding tank capacity 'ls- No. of tanks New Installation A eplacement_ Prefab Concrete *Poured in Place -Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) S 2)x_3) '..5 Total Absorb Area to/!~ sq. ft. New Addition Replacement *Fill System Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length, Z' Width 7' , Depth Tile Depth ).I No. of Lines 7 Seepage Pit: Inside diameter 7-Liquid Depth Tile Size '1_ Percent slope of land ° Z 67~i Distance from critical slope 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 C.S.T. # Z Z lX and other information obtained from S f6 tit (owner4iider). ~j.. Plumber's Signature MP/MPRSW# .1o 5- Z Phone Plumber's Address a - PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). .7c G' -T 7/~\ Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application Fees Pa'd: State /O. r7 C7 Co n y Dat J- Permit Issu (date) _Issuing Agent Name L e4 Inspection Yes~No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 EH .115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION 4 '/a,&A4_'/a, Section/n, -WN, R,~,-(or) W, Township or ft+n+ei l+ty Lot No. , Block No. County ~U Subdivision Name Owner's Name: S s Mailing Address: TYPE OF OCCUPANCY: Residence ✓ No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS ~ f PERCOLATION TEST SOIL MAP SHEET SOIL TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 1 Or/ # low " SOIL BORING TESTS TEST TOTAL D&TTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OB ERVED STIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B- 72- &M e, 7 7Z ",5 //C . S PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. JT i Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. E r~ e I O f o 14 1 p i fN ~ .U 1 a , I, the undersigned, hereby certify that the soil tests reported on this form.were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) Certification No. Z z 9 Address Name of installer if known CST Signature COPY A - LOCAL AUTHORITY AS BUILT SANITARY SYSTEM REPORT I'I OWNER TM S z>~r5c~~ TOWNSHIP Sfc~_r?=,-__ St-.C.0 I'3fN-07W ADDRESS it yV Z C. ST. CROIX COUNTY, WI. SOONS I.N . SUBDIVISION n i LOT f A LOT SIZE__P PLAN VIEW Distances and dimensions to meet requirements of H63 rcc>,1 ~VE$XTHING WITHIN 100 f'LE'I' OF SYSTEM - ~1 -f 01. i a e otYrrow I FF, SC ~ Vr Gar! BENCHMARK: (Permanent reference Point-) Describe: t,5.ij ~r ~osrt ~ic~c . &rl Jrc1 1r~1 5. CAL M r' L Elevation of-vertical reference point: /0-0 61 -Slone at Site: SEPTIC TANK: Manufacturer: lower-rS ~~~rn¢y _Ll~~ Liquid Capaci_t y : Number of rings on cover Tankkk manhole cover el e.vatton Tank Inlet Elevation: j~3'' Tank Out Let Elevationn: ' PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle _ gallons; total cap;ici.ty o. distribution lines gallon: size oT` pump_ huaJ; gallon per minute horsepower brand naim. of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole epover Type of warning device SEEPA E PIT SIZE: _NumFer of pits _ Lest inm(21 (2 1- feet liquid dept seepage pit inret pipe-elevation _ bottom of seepage pit e evation _ _ feet. SEEPAGE BED SIZE: number of lines width / oZ 1et%Lh_3~ Li I e slept 13d SEEPAGE TRENCH: width s len th PERCOLATION RATE (,taQ , REA REQUIRED AREA AS tffriuGr 940 INSPEClO JO i - - ~ DATED PLUMBER ON LICENSE NUMBER y~ "?G~ DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &.HdOAAN hELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O BOX 7569 ' BUREAU OF PLUMBING MAIII> I SO N, VIII 53707 A ate Pla CONVENTIONAL ❑ALTERNATIVE Stnl.D. Number: (lf a assignssigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: 1)efadz's c-lv BENCH MARK (Permanent reference point DES RIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. 6 Jig Name of Plumber: MP/MPRSW No.. County: Sanitary Permit Number: SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. r747,15 LET ELEV.: TANK OUTLEELEV. WARNING LABEL CKING COVER PROVIDEDPROVIDED: { / V RYES ❑NO DYES f>JN0 BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY W : BUILDING VEN TO FRESH ALARM FEET FROM So LINE / AIR INLET: YES ❑NO DYES ❑NO NEAREST P/ `/o DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY. MP JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ❑NO DYES ONO GALLONS PER CYCLE: UMP ND ON OL OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN f FEET FROM LINE: AIR INLET: PUMP ON AND OFF) &ES ❑NO NEAREST 1110 SOIL ABSORPTION SYSTEM. Check the soil m isture at the depth of plowing Lt -c I H AMETER 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 CONVENTIONAL SYSTEM: NI DTH. LENG TH. - NO. OF ID, STR. PIPE SPACING. COVER INSIDE DIA.. #pITS. LIQUID BED/TRENCH R_ TRENCHES / MATERIA PIT DEPTH: DIMENSIONS S /P FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING: VENTTOFRESH BELOW PIPE ABOVE OVER ELE V. N LET ELE V. END: PIPES FEET FROM LINE G AIR INLET. ~I 2 V 2Sf NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope CheckAfi~ to re of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mo d sysrt'e s -:w make certain that it ON REVERSE SIDE. SHOW ELEVA- ' ets t I ria for medium sand. TIONS MEASURED. DYES ❑NO SOIL .`OVER. TEXTURE. - PERMANENT MARKERS. OBSERVATION WELLS. f DYES ❑NO DYES ❑NO DEPTH OVER TRENCH;BED DEPTH OVER TR CH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER EDGES. DYES ❑NO DYES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH NIDTH LENGTH TRENCHES ATERAL SP CING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS f, MANIFOLD PUMP MANIF D DISTR r E MANIFOLD MATERI7~~ DSTRP IPE DISTRIBUTION PIPE MATERIAL & MARKING EL ELEVELEVDI'Jl. ELEV. . DIA.: ELEVATION AND ~ DISTRIBUTION INFORMATION HOLE SIZE HOLE SP ING DRILLED CORRECTLY COVER MATERIAL PLANSCAL LIFT CORRESPONDS TO APPROVED DYES ❑NO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES ❑NO (~D~YES ❑NO NEAREST- J'A (p. S 5 j Ot -7r ( Sketch System on Retain 'n county file for audit. Reverse Side. ~j / SIGNATUR ITITLE: DILHR SBD 6710 (R. 01/82) LICATION DEPARTMENT OF , 8 ~ SAFETY & BUILDINGS INDUSTRY, fOR' NITARY DIVISION LABOR'AND A ~ r'~F P~ IT P.O. BOX 7969 HUMAN RELATIONS P8 [(PL 7) MADISON, WI 53707 2#46 1,98Z Attach plans for the system on paper not an E90561 inches jay e. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must sd own. All appr a separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An in P p e must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number mu The owners copy or a legible reproduction of the soil test report must be included. Proper Owner: Mailing Addr Property Location:. City, Village or Township: County-°- " t/4 t/4S iT NiR E (or) W 51-,( Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: ) NA (If ssi new - TYPE OF BUILDING }n/{~ Number of Public* ❑ Variance* ❑ Other (specify)* f \ Bedrooms: ❑ 1 or 2 Family *State Approval Required. NO 11 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 600 A HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: r. EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): >VNew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit F-1 Alternative (specify) Seepage Trench rte.=. Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): 19 Private ❑ Joint ❑ Public N A I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. N e o Plumber: Sign at r WIIliMPRSW No.: Phone Number: U 1 ti ~f O C, r 2 r feL__~ /.S 5 175 )~'Sl~'" 5/_3S Plumber's Address: Name of Designer: A CK cdv l S COUNTY/DEPARTMENT USE ONLY Sign re of Issuing A nt: Fee: Date: Sanitary Permit Number: lior APPROVED • 7 "°(o ❑ DISAPPROVED' eason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (N.03/81) F. s Department of Industry, Labor & Human Relations State Division of Safety & Bldgs. State of Wisconsin Bureau of Plumbing Platting & Fire Protection P.O. Box7969 Madison WI. 53707 Tel. 608-266-3815 I IN AL L CORRESPONDENCE Tc1U_)9_V-5 G ~P_IM-eN'T ~v o D,, c -is REFER TO PLAN c~ I IDENTIFICATION NO. S ~o / 7 L E OF PROJECT ~IB ) 19/ TYPE OF APPROVAL 0 c.-r.9- rl S l~J APR 5 rs8 r✓. STREET AND NO. / ZONI 2 lid off/ f11 a..- / t4"'q cr'Talwi / , ` v / CITY OR TOWN COUNTY STATE ZIP S T,b ~cj G , C.cJ 14 ci i OWN R Gentlemen: Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work may commence. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require- ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto- matically void this acceptance. Sincerely, James.Sargent-Bureau Di or DATE: PLANS REVIEWED BY: ' lo-a~ 7<7 K44 cc: DPS M7 Owner DILHR Plumber H & R (2) Mfg. Rep. Bur. of Health Fac. & Services DILHR SBD-6099 (N. 06/80) Rec. & Env. Services SBD 6678 (9/81) Ift 100a) STATE OF WISCONSIN DI LHR Detaph And Return Upper DIVISION OF SAFETY & BUILDINGS .Portion - Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 178 Any Return Correspondence P.O. BOX 7969 R MADISON, WI 53707 608-266-3815 DATE: Z I 117 PROJECT: Iw► a~c► ; r1 e_ S~ o o w e.V S Gew►e 'r v a ~J u S tiLnf SI Ry -r-31 t4j 3 e-Li llc k w1o--4D w, -rW_k(-r0 A4 o -1 S- T, G v o 4_ C('o PLAN ID. # Z O fJ ZZ DETACH HERE PROJECT NAME PLAN ID. # `%Z OO Z ~Z This is to acknowledge receipt of your plans and specifications for the above-indicated project. I? V Preliminary review indicates the required fee is $ 'Il Fee Received is $ z Y Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming. Plan accepted for review. ❑ Plans being returned. No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW. held in abeyance. 1. Plan Submission ❑ Complete data relative to anticipated use of bldg. ❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed. less specifically noted. ❑ Deed restriction required (1 copy). ❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy) ❑ All information submitted shall be signed, dated and sealed or stamped in accord with Section H 63.08(2)(a) Wisconsin Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks ❑ Profile of holding tank showing vent, manhole alarm and manufacturer if precast. Complete construction details if 11. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed. ❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of and notarized. 0 copy) government (sample enclosed). ❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement for pressurize distribution. ❑ Soil boring & percolation from county (1 copy). test data. ❑ Plot plan showing location of holding tank with lateral dist ❑ Cross section of system. ❑ Pipe lateral layout. antes to any building, wells, water service piping, water ❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road, ❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point. I. Private Sewage Disposal Systems V. Lift Pump Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons 1 tion system extending 25' on all sides. pumped per cycle. ❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main. Location of area suitable for replacement system provide ❑ Detail & model of pump or automatic siphons including soil data. size, pump curves, drawdown and average flow rate GPM. ❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or sewage disposal system to buildings, lot lines, well, water siphon(s). course, swimming pools, water service piping, Etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission) Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench system. before side slope begin). ❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill. tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff. 2. Indicate whether the following facilities are present. Floor drain yes no X Number of drains Food waste grinder yes no X Dishwasher yes no X Automatic clothes washer yes no Number of clothes washers 3. Septic tank capacity _ /0 Q a >C Holding tank capacity Septic or holding tank manufacturer 4. SEEPAGE TRENCHES: total square feet width of trenches length of trenches depth number of trenches SEEPAGE BEDS: total square feet gl,~P O width length of bed _3 S depth SEEPAGE PITS: total square feet outside diameter depth below inlet total depth from top to bottom of pit Signature of person completing form: FOR DEPARTMENTAL USE ONLY r/ ' R Address j p 0 i Telephone Number Wk Date - PLUED MBING ME rOF DUSTRY,Uk" ~ A PCs ~iU,%0,t?N RELATIONS N OF SAFET`( ND UILD 4G N~Z SEE 0014R PONDENCE l sic G o_ 'oa'f f P V s 1 r -r~ ~ - m N ~ t ~ ~ I c C W i ! v 4 6-' I rrn - n y~ M ~v Cr ± O 1! ° M e , C L ~V - \ ,Q o W 4 N Z Z 0 a c / M b ! 1 m o a `n C I ohs L I lr! y p , 'All ri P1 b: 60 1/78, • PROJECT DETAIL DATA SHEET 82 -0 0262 NAME OF BUSINESS 6 LEGAL DESCRIPTION 19 OWNER 5 MAILING ADDRESS K 11z_)_0 , Esc '~T -fi~FGI1Vff R, i ,gyp r- c, ADDRESS PLUMBER D"ES-iGNER ~j!- 41 E, &j ZIP 7 TELEPHONE NUMBER 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building New building Addition ( ) Apartments and condominiums . . . Number of bedrooms ( ) Assembly hall . . . . . . . . . . . Seating capacity ( ) Bar . . . . . . . . . . . . Seating capacity # of meals served ( ) Bowling alley . . . . . . . . . . . Number of lanes ) With bar Campground and camping resorts . . . Number of sewered sites { Number of unsewered sites Total number of sites ( ) Camps . . . . . . . . . . . . . ( ) Day use only Number of persons ( ) Day and night Number of persons ( ) Catchbasin . . . . . . . . . . . . Number ( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons ( ) With kitchen Number of persons ( ) Dance hall . . . . . . . . . . . . . Number of persons ( ) Dining hall . . . . . . . . . . Number of meals served daily RECEIVED ( ) Dog kennels . . . . . . . . . . . . Number of enclosures 1 ( ) Drive-in restaurant . . . . . . . . Inside seating capacity FEB 4 1982 Car-service Number of car spaces ( ) Dump station . . . . . . . . . Number of dump stations OLUsIN© 13UREAU Employees ( total of all shifts) Number of employees 2it ( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit Number of units with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff Number of office personnel Number of patients ( ) Mobile home parks . . . . . Number of sites ( ) Nursing homes . . . . . . . . Number of beds ( ) Parks . . . . . . . . . i . Number of persons ( ) Toilets ( ) Showers ( ) Restaurant . . . . . . . . . . . . . Seating capacity ( ) Dishwasher and/or disposal? ( ) 24-Hour service I Retail ctnrp+~i V 82 0 0 2 6 2 C r D5 s 177 mac,- . .1J V 4 t^t1 7 5 A 4 ICusfx t5cpj a ~,ncc1 x j>QQ i C' J RECMVM x F E 6 4 1982 h4UiIItEW BUREAU 01455 lx 3E",Ox 4: PLUMBING I X CA* 03 na& V E D DEP THE OF IND3 ,STRY, AB' AN HUMAN RE IONS DIVISION OF SAFETY NO S ILPJAS StE CO R NDENCE C' Department of Industry, Labor & Human Relations a' Division of Safety &,Bldgs. State of Wisconsin Bureau of Plumbing Platting & Fire Protection P.O. Box7969 Madison WI. 53707 Tel. 608-266-3815 y INALL CORRESPONDENCE REFER TO PLAN IDENTIFICATION NO. I- X 0 0 ~ C, NAME OF PROJECT _t I°d • i 'r ~~.j r2 11J g 9 v •"~l I C f f_ s. TYPE OF APPROVAL _ 'lQ t -X e'-"tea . STREET AND NO. ` V ~ f }T c.t t r f K / jo $ 982 CITY OR TOWN COUNTY STAT ZIP O ly~/~Ib' OWNERi r ~ r-ti h ttI r'~.p Gentlemen: Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work may commence. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require- ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto- matically void this acceptance. Sincerely, ~lftsA~ James Sargent-Bureau Dir or } PLANS REVIEWED BY: S y _ DATE: cc: DPt=f9WS j, Owner DI LHR P{_. Plumber H & R (2) Ce"ty.-.. - Mfg. Rep. Bur. of Health Fac. & Services DI L H R SBD-6099 (N. 06/80) Rec. & Env. Services SBD 6678 (9/81) (Plb 100a) STATE OF WISCONSIN DILHR Detach And Return Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 178 Any Return Correspondence P.O. BOX 7969 MADISON, WI 53707 608-266-3815 DATE: Z._ a PROJECT: FLAN ID. # Z_ r) 7- DETACH HERE PROJECT NAME PLAN ID. # [~~ZT^t`` This is to acknowledge receipt of your plans and specifications for the above-indicated project. Preliminary review indicates the required fee is $ Fee Received is $ G / rtil, ❑ Underpayment - Please submit the additional fee. El Overpayment -Refund forthcoming. ❑ Plan accepted for review. ❑ Plans being returned. 1 No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW. held in abeyance. 1. Plan Submission ❑ Complete data relative to anticipated use of bldg. ❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed. less specifically noted. ❑ Deed restriction required 0 copy). ❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy) ❑ All information submitted shall be signed, dated and sealed or stamped in accord with Section H 63.08(2)(a) Wisconsin Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks ❑ Profile of holding ran:: showing vent, manhole alarm and manufacturer if precast. Complete construction details if II. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed. ❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of and notarized. (1 copy) government (sample enclosed). ❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement for pressurize distribution. ❑ Soil boring & percolation from county (1 copy). test data. ❑ Plot plan showing location of holding tank with lateral dist- ❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water ❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road, ❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point. III. Private Sewage Disposal Systems V. Lift Pump ❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons tion system extending 25' on all sides. pumped per cycle. ❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main. ❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons. including soil data. size, pump curves, drawdown and average flow rate GPM. ❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or sewage disposal system to buildings, lot lines, well, water siphon(s). course, swimming pools, water service piping, Etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. V I. Svstems In Fill (Fill must be placed prior to plan submission) ❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench system. before side slope begin). ❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill. tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff. < DEPAfITMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, i DIVISION LABOR AND PERCOLATION TESTS (115) MADISON W 7969 HUMAN, RELATIONS , LOC TI jt~yj/ SECTIO~~ ~ ~ r) TOWWNS IP/MUNIICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: COUNTY: A "T OWIJNER'S BUYER'S NAME: I MAILING ADDRESS: T USE DATES OBSERVATIONS MADE NO. BEDRMS.: CO ME AL DESCRIPTION: IMOFILE DESCRIPTIONS: C / y I NT TS: ❑Residence P`JNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable or systemONVENTIONAL MOUND: IN- ND PRESS E: YSTEM-I - ILLHOLDING T NK: RECOMMENDED SYSTEM:IoptionaQ ~SEI ❑s s❑ ❑s u s If Percolation Tests are required 11,ESIGN TE: SYST-EUZLE If any portion of the lot is in the under s.H63.09(5) (b), indicate: I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 1,2 F~ BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 0 IV J* o - Ts, B-3 S"; 3 r(;, S s~ r~ B-y 1, ?-o2y _54 o~Z B- L2 1 0-7 547 -62S~ c4 ;)4 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P_ /90 3; P_ P-. P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION -t-Q{ [yam a.0 # i i-k y t , 5 t,I [ ...n 4 CIO k n : 40 b. z 1, the undersign F, hereby cetify 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 (pri TESTS WERE COMPLETED ON: xr e _ /I-// S/2- ADDRESS: , , CERTIFICATION NUMBER: PHONE NUMBER optional): CST Se19NAT DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHRSBD-6395 (N. 03/81)