HomeMy WebLinkAbout042-1034-95-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER .Q
ADDRE S-)
~
SUBDIVISION / CSM# LOT
_N-R~-W, Town of (,Jail1\Q~r~
SECTION. l,/ T Q
?.off g
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• A !
r T:
INDICATE RTH A
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
/ /
BENCH ARK: 514111;9 N 4J Ctoyr~
ALTERNATE BM:
SEPTIC TANK / F=1; 01191 R /
Manufacturer: Liquid Capacity: Joao
- 1
Setback from: Well 7a House QZ3 Other
Pump: Manufacturer Mode l# Size
Float separation n~~ Gallons/cycle:
Alarm Location WA
S :SOIL ABSORPTION SYSTEM
Width: Length ZZ3 Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: S0,5 House 3 2 Other
ELEVATIONS
Building Sewer ST Inlet; 95.. s ST outlet 9 O
PC inlet PC bottom Pump Off
Header/Manifold II(, Poo/ Bottom of system
Existing Grade 740, Final grade 9`
DATE OF INSTALLATION: 9,
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93 : j t
r
L~D14sa~p:~rtGllAiaRlusty3.29.28.2tATE SEWAGE SYSTEM County:
Labor and 1Luman Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitar#rritW3EN
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI .
i v.: nsp. Elev.: a cnp i n: Parcel Tax No.:
IGu C~ ~O ,G~ S-
042-1934-95-0901
TANK INFORMATION ELEVATION DATA A9300240 -
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (~t~ i S C_ <; i 1 C` . l . ; ✓ Benchmark .
Dosing
Aeration Bldg. Sewer { ~nnt p /`ns
Holding _ St/ Inlet (o ~3
TANK SETBACK INFORMATION St 1#r outlet J
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic a NA Dt Bottom
Dosing NA Header-
Aeration NA Dist. Pipe 87 g/,,
Holding Bot. System g 93
PUMP/ SIPHON INFORMATION Final Grade
Manuf rer errand S 8a 00
Model Number G
TDH Lift Friction SYs Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of T enches PIT-"°~ No-omits ` Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Ma
SETBACK
INFORMATION CHAMBER
TypeO F~ Mo a Number
System:!cX ~S OR UNIT
DISTRIBUTION SYSTEM
Header /A/ 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 Syste
Depth Over A/ Cs, Depth Over s~ sA xx Depth Of xx S Sodded xx Mulc e
Bed1'Trench Center ftld/-Trench Edges S' Topsoil E] Yes No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: WARREN 13.29.28.207B
Plan revision required? ❑ Yes
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
3
SANITARY PERMIT APPLICATION
=:7ZDff1 LRIn accord with ILHR 83.05, Wis. Adm. Code COUNTY
- Sf cro) r
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 1 12nZeviousapplicatlon
-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
Dsh A Gr Q.4^ 5'1(2\a1 AjbJY4 56 %4, S l T,Z? AR R /S/ r) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/ e4 7 .2, o,4 w 2_ A
CI , STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
~V- W
5 0;1.
3- 1
11. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned 0 VILLAGE W4 M rs ^
El Public ~ 1 or 2 Fam. Dwelling- # of bedrooms 3 PARCE1 TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) Q~ cam' - d,3 - ~7
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 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
50 Hotel/Motel 90 Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2. XlReplacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ~ Seepage Trench 22 El 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
REQUI ED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
//Ou 1130 • f7'~ 1 t! A 9 3, 7 Feet t96 o 7 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank Am P, -A~. - - 1:1 El ~=o Fj
Lift Pump Tank/Si hon 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 Signatur o Stamps) fV/MPRSW No.: Business Phone Number:
Ga l of n 1'e)W4 If C I 15 63 71-S a 6
Plumber's Address (Street, City, State, Zip Code): n
IX. COUNTY/DEPARTMENT USE ONLY
L] Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin ent Si rStamps)
,Approved ❑ Owner Given Initial 13 Surcharge Fee)
Adverse Determination ' a^(v -
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
398 (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 renevmai any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit i;sr:ing author1y.
4. Changes in ownership or plumber requires a Sanitary Pert-nit Transfer/Renewal Form (SFf) 63991 to be
subPritted `o the r.ounty prior, to instailatsoR..
5. Ow-!At ,E Je . ys!er is ;rust tie properiy riiaintairied. The sepl: tank(s) must Le pu; .l:ed i,y e !ieens-66
purr pr per whenever necessary, usually. every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your locar code a0ministrator 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 bQ 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 a!! information requeste'l in ##1-7.
VII. Tank ~J~rr-nation. Fill in the :rapacity of ew-Fr, ;ie,v ai-id/or exist Link, list tie tote) number of
tanks and manufacturer's name. Indicate pre" .i) or site consteu•_'.;d and tank material, Com: fete for all
septic p i-op/siphon and holding tanks r system. Check s ~rreri al approval orl ; it l inks received
enperrnr-,Wai product: approval from DIL'Ji",,
VIIL Responsibility statement. installing plumber i<: to fill in name, isr~e-se number with appropriaie prefix (e.g.
MP, e'c.), address and phone number. Plurnbe+ must sign apphc-,--- -n form.
IX. County/Department Use Only.
X. Counter/Department Use Only.
Comp ete plans and specifications not smaller than 8'h x 11 inches must be submitted t:) county. The
plans •r;!.;st include the >ollowing:.A) plot rp!an, drawn to stmt - -,Ath cornplEte di,'T;enr ion!-, =ocation of
holdir~ ta. k(s). septic, tank(s) or other 1.r} rnerit tanks; bu i ~ r vers ~ e! s; wafer aria r •iaier service;
streams =rcl lakes; puirp of siphon i.gnks -iistribution boxes so;i eesorotior systems; re )1-( e!nen: system
areas and the location of the building Pal 9) horizon.;:' ,.,,J ~ ertica. _ e --aiori refer )Ohl
C) complete specifications for pumps and controls; Bose voiunie. elevation differences; fric; on lose.; pump
performance curve; pump model and pump manufacturer; D) cross section cf the soil absorption system if
required by-tfre-county; E) soil test data on a 11,kfarm; and F) all siziag, information.
- - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 41°) inciuded the creation of surcharges (fees) for a number sf
regulated practices whic` can effect groundwater
-The monies collected throi ,c i r. -ese siircharg(E %.r3 used for my 0or!'
`wate'r'contarnination investigations and establishment of standards.
SBD-6398 (R.11/88)
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Wisconsin Department Relations Industry,
Labor and Human Relat+ SOIL AND SITE EVALUATION REPORT Page -L- of
Division of.Safetg & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but G roA'
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
bri & G r-Q-4th _~l Q~C\ GOVT. LOT lVaj 1/4 1/4,S/ T oZ N,R /,~',*or)W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1(7-> 14 w I ` D. N f 16- ))p. 1.r A
STATE ee ZIP CODE PHONE NUMBER ❑CIT,Y t❑V LLAGE 0 N NEAREST ROAD y
r` W ',T S U.Z 04- ) W ' a
[ ] New Construction Use Residential / Number of bedrooms R [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow JrO gpd Recommended design loading rate ~_bed, gpd/ft2 .~_trench, gpd/ft2
Absorption area required /U. bed, ft2 / a 5 trench, 11:2 Maximum design loading rate NIA. bed, gpd/ft2 'q trench, gpd/ft2
-7- r
Recommended infiltration surface elevation(s) 93,7 ft (as referred to site plan benchmark)
Additional design / site considerations f r.S Y.~L+ o y, o? S X //4
Parent material ___P L~e'l C' I a c , o,~ pr1.4,F. Flood plain elevation, if applicable )y 1/ lh~ ft
-7
S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDIN TANK
U= Unsuitable fors stem S❑ U l$ S❑ U S❑ U E] S U ❑ S .QI U El S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
/oYe
a G 5A / - 3 - S bk m4v- C'w - •.rj
Ground .3 -S/ /Dy2 y bk N ~LO j~ - y
elev.
ft. GW
G.7
Depth to 5 4 /o R S - 5 C W , y
limiting
factor
Remarks:
Boring #
C L4
a 9-33 /a R s
yo _S 1.24 -.5
CL"
Ground
elev.
C Li
3-11's ft.
Depth to
limiting
~factor
Remarks:
CST Name:-Please Print - Phone: , 71
n e r5 r
Address: l 9io 9 ~S wtr 5 Y I
Signature: ~ Date: _ aO -S CST Number:
PROPERTY OWNER D6r►a~ G rt~~~`e~d SOIL DESCRIPTION REPORT Page of
R
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bwxbty Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxh
f ' 1 a _t ~o s~ ~{r sbk rn~s C0 1 hi S
f '
Ground 33 a s / - - sb v~'1 V CU-)
elf v, gft. ~d'✓rS /b Q b s 5~1~~ 1- C ~,J S
Depth to 5bk ylllc~ r
limiting
factor
Remarks:
Boring # _ GW M S
S
SA-e m~ r C W INS
15 -1-4 58 VA J
Ground y CL~
elev. Sy._ 5 - 5 / S s 4 k m y ~I
Mft.
s o-m;s m
Depth to
limiting 96
S YIl-s 1
Ake
factor
a ~f
Remarks: o
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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1( PAGE OF
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S Sec u o
Wi CrvS [
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SY°~3
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade
20- 42" Above Pipe _ 4' Cast Iron
To Final Grade Vent Pipe
Mash Hay Or Synthetic Covering
MW 2" Aggregale
Over Pipe
014tribution -Tee
Pipe 0 0 0 0
i 6" Aggregate o Perforated Pipe Below
Beneath Pipe
o -Coupling Terminating At
Bottom Of System
96,7
Pro(~ose~ ~I~k~ 1gr~.~l< , .
SOIL FILL
DISTRIBUTIOI,I PIPE
APPROVED ~4WrETIC COVER
~4. /q,%rf RII~t- op, 9" OF STRAW
r OF IF OR MARSW HAS
°
° !a OF J2-Zl/2 AGGREGATE
~L E
as a, s
DISTR19t,TIOM PIPE TO BE AT LEAST _ WCHES BELOW ORIGINAL GRAOE
AM[) AT LEAST?-0 INCHES BUT 1.10 MORE THAI) 42 IUCHES BELOW FINAL GRADE
MAXIMUM OWN OF EXCAVATION FROM ORIGWAL 6KADR WILL BE. - 0 INCHES
rdKIMUM 9C " OF EXCAVATIOW FROM 01KIfaNAL GRAVE WILL BE _ INCHES
9 oot-,,~
SIGNED:
LICEMSE IJUMBER: 3
DATE:
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ,0CY1 Q\8 Cc-) ~ ,7~ 1 ~,1d
ROUTE/BOX NUMBER 7.2, /4~ (FIRE NO. 17z
CITY/STATE ZIP 15-Y0:--3
PROPERTY LOCATION: 114 1/4, Section 1--T , T.Ry N, R W,
Town of o.M.Sl v-, , St. Croix County,
Subdivision A 1 R , Lo t No. WA-1
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. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 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
systems properly maintained.
The property owner agrees to submit to 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 form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date. r~
SIGNED
DATE
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
• APPLICATION FOR SANITARY PERMIT
ETC - 100
This application form 1s 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/conttactot,(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 D,, ~ v n"s~
Location of property A114J 1/4 1/4, Section, T~N-R LV
Township
Nailing address t y a
loo ~ -tie ~~s c G' y d ~3 -
Address of site
Subdivision name
Lot number Pr
Previous owner of property 'RUkSS-e-~
Total also of parcel 5 Q-c'~
Date parcel was created
Are all cornets and lot lines Identifiable? Yes ~~Jo
is this property being developed for resale (spec house)? Yes _N0
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAaE NUMBER, and
the BEAL 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 Cestified Survey Map, the Certified Survey
Map shall also be required.
---------------------------------------------------------7---------------------
PROPERTY OWNER CERTIFICATION
I(We) cattily that all statements on this form are true to the best of my (out)
knowledge; that I (we) am (are) the owner(s) of the property described In
this Infotmatlon form, by virtue of a warranty deed recor d in the Office of
the County Register of Deeds as Document No. 3 9 -7 6 it and that I (we)
Presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for khe
construction of sold system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
'('I Applicable)
Signature of Owner Signature.o.f Coiff.
rZ g Q3
Date of lgnature Date of SlFa-tt:r,
DOCUMENT NO. STATE 'BAR OF WISCONSIN-FORM 1
WARRANTY DEED
339708 rVOL 5'3 PA- E'25 THIS SPACE RESERVED FOR RECORDING DATA
Russell D. Klint and Deanna REGISTERS OFFICE
THI DEE jnade be t7°teen
T. I~~int, us an an wi a an each in is 5T. CROIX CO., WIS.
an her own . r i g t Recd. for Record this 2nd
Grantor
ana Donald reen' i~ , an Berna i.ne ogt, day of May A.D. 1977
as joint tenants t 8:3o A.,#
i ; tj 1 Grantee, t.
W i t n e s s e t h, That%the said Grai}tor for a valuable considerate n Thirt - 1W of Deeds
Seven Thousand.-.Fiye'Hundred Dollars (37,500.00
conveys to Grantee the following desG'be.4!real estate in St. Croix County, RETU TO
State of Wisconsin: Y7
A parcel of land located in the SW-14 of the
SE-14 of Section 13-29-18, St. Croix County, TaxKey#
Wisconsin, described as follows.: This is homestead property.
Commencing at the Sh corner of said Section 13;
thence East (assumed bearing) 1040 feet along the South line of said
SE-14 of Section 13 to the point of beginning; thence N10421W 484.5
feet; thence East 280 feet, more or-,less, to the East line of said
SW314- of SEA; thence South along the East line of SWU of SE14- to the
Southeast corner of said SW-14 of SE-14; thence West along the South
line alb Section 13 280 feet more or less to the point of beginning..
TRMSFE
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining-, FED
And Russell D. Klint and Deanna`V. Klint
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and rights of way of record
and will warrant and defend the same. i
Executed at ` this day of 19 7 7 .
SIGNED AND SEALED IN PRESENCE OF
ussell D. K1int
Deanna V. Klint
\
(SEAL)
(SEAL)
e_
Signatures of
authenticated this day of 19 .
Title: Member State Bar of Wisconsin or Other Party
Authorized under Sec. 706.06 viz. NEc~ ~A~vSivRE- - . 11
STATE OF gH9e9N&fff l
6,4 L/,514 Jt as. ~I
Personally came before me, this a3 day of 19 7 7 ,
the above named Russell D. Klint and Deanna Klint
to me known to be the person S who executed the foregoing instrument and acknowled d,the s
~,~w Iii / t
! C \
This instrument was drafted by o-~ A R
- -
,
C L Gaylord, Attorney Notary Public x'county,
River Falls, WI M9P?FMissl0
n: ptres 8rli ?7,.1977
The use of witnesses is optional. My Commission (Expijby~'(T
Names of persons signing in any capacity should be typed or printed below their signatures. Ka.MU1erC4n% ra®
Wi~,.W, WIMM\M
WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 1 - 1971
Wisconsin Department of Health and Social Services
D Z ~b / 0 K 1
Plb. #67 3/70 4;M Ca Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Fame Address (Street, City, Zip Code)
C
B. LOCATION OF PROPERTY WIERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY. 1-% 1 't'om
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP \J '7
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? ,k YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION /t REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE ISSTALLEDs s
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial Other
Specify
Number of Persons to be Accommodated 7 Number of Bedrooms 1-7
Fe APPLIANCES, ETC: Food Waste Grinder YES X NO Automatie Clothes Washer YES NO
Dishwasher YES X^ NO Automatic Potato Peeler YES Y' NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION r
Names 4 Addresss License Numbers
I i~- MP
Signature of Applicant: C - y ! MP RSW
Address:
H. (To be Completed by Issuing Agent) /
Date of Application. Fee Paid = 1 ~ Permit, Issued (date) 7/ 7 2 /7 L Permit Number L7.-2 7
Agent (Name) •l
Town, Village, City, County, etc.
(Specify)
Note: 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 $1.00 or each septic tanK and the third copy
of the permit (canary) 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
1. DATE RECEIVED v ACCEPTED BY RETURNED
(Initials) (Date) Sae Lurre~ s.)
FEE RECEIVED VALID. No. Q Y 3 & O PERMIT N0. <~~2
es or No
REVIEWED BY APPROVED DATE
(initials) Yes or NE
COMPLETE OTHER SIDT
1
/ 1
SEPTIC TANK PERMIT NO. 77
REPORT ON SOIL Pt RC0LATI0N TEST
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECTIN
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
PERCOLATION TEST
Test Depth Character of Soil Hours Water Test Time Drop In or Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period One Inch
Example
P - 0 3611 To Soil 1011, Clay 26" 25 Yes or No 30 1 2 212 -1/2-- 60
~ fGZ j•:~~ c~~~
7 a, Top 1, /7/
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 36" Below roused Abso tion U stem
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B _ 0 72 it 7211 Black To Soil 12" C1 181' Sand 181 Gravel 241
2 /v~C~ ~~L ~j: } r( ;YGa r L/Y
T-
RWORD DATA FROM MINIMUM OF 3 BORE HOLES
i
YPE OF OCCUPANCYt
RESIDENCts Number of Bedrooms OTHERS (Specify) Number of Persons
D WASTE GRINDERS Yes No -4- Dishwashers Yes No Automatic Clothes Washers Yes No ^y
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size 7 No.Lin.Feet L L 1> Trench Width Depth Number of Lines
Seepage Bad: Length Width 1 Depth rZL_ Tile Size No. Lines
Seepage Pitt Inside Diameter Liquid Depth
I, the undersigned, hereby certi-y that the percolation tests reported c.i this form were made by me or under N- super-
vision in acoord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME TITLE
Type or Print
or MASTER PLUMBER LICENSE N0.
REGISTRATION NO.
ADDRESS. r f G1 L~ rC. L L S
DATE SIGNATURE r
T