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HomeMy WebLinkAbout006-1074-80-000 C c I Q-0 C) ) O c 0. 0 o O 3 •M o O fl. ~ h co n C (D Cl c m ~n ^ p L -Q • T a 'y N ~i t ~ p C 'Q U d- m mCD O w C N .n C T O C O C > O 'D i Cl. N T C (n O. = C O Er o>ooa~L U n E m.o~ ~U o m o°0-oc oo O C n m z n N C 7 o .O C N il-' LL N a'O U E C a) a) O > 'C3 U) n c L > C U~ o)U w~ o Q (D H 'N U) m o..a M I ' Q) Z E O Z O V `O Z r i CL Co co F- Z O Z c d 2 ~ 2 c V1 I- r m N r U) C) _ 7 d C co •N 7 m > L O O. m _N T O O O C Q N Q E Z d Z o ~O -2 U_ N L z R' c m O L _U N 10 E ~ Z yy fp ~h n V) G 'm c v u a`o O C 0. a m r, m N to fA E v fn c O O O •~w M Eaaa (D 04 N Vi J U 3 rn Cl) Z ° C) O O o ro o m v n O ~ m Z m T N w Q U ui N CD o a ° ° Lf) rn co o a N O n O F0- L C E O try,) C. 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RD. O OR S Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labornd Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX ` (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149290 Permit Holder's Name: ❑ City ❑ Village JV Town of: State Plan ID No.: GOODRICH, ROGER L, B V, D W CYLON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 006107480000 TANK INFORMATION ELEVATION DATA A9200140 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. I f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: r SANITARY PERMIT APPLICATION caQ1LHR s In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA P RMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ILI 8% x 11 inches in size. ❑ clfeck Ir re soon to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER ATION. 1. APPLICANT INFORMATION PLEASfi P NT ALiANFIOV PROPER OWNER PROPERTY LOCATION Q1 Cow - " '/a S , N, R(or) PROP TY , OWNER'S MAILING ADDRESS LOT # BLOCK # S11 ' TY, STATf Q u✓ W ZIP DE-7 PHONE NUMBER yG SUBDIVISION NAME OR CSM NUMBER -54 - 01 II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILL NEAREST ROA o Y S RWL'W F: L? Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL X NUMBERS) r / n~ III. BUILDING USE: (If building type is public, check all that apply) © Q (o ^ f O 7'-( - ~S v 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) J~ ew 2.E] Replacement 3. ❑ 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 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43-9-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) ELEVATION Feet Feet VII. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tank Tanks structed Se tic Tank or Holdin Tank /040 GVC L 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): Plu b 's Si atur :(No tamps) MP/MPRSW No.: Busin ss hone) lC~Ch~iY ~.b ymbe J Plumber's Address (Street, C!'tyi State, Zi ode): IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e Issued Iuig 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 -s , 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.. 11. 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. VI1. Tank nformation. Fill in the capacity of every new and/or existing tank, iist the total gallons. number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete far all septic. pump/siphon and holding tanks for this system. Check experimental approval only if `anks received experimental product approval from DILHR. Vlll. 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 81/4 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; close 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. I SBD-6398 (R.11/88) 1 PRIVY INSTALLATION AGREEMENT -COPY TO BE ATTACHED TO THE SANITARY PERMIT APPLICATION. Property Owner(s): Reserved For Recording Data Mailing Address: Location: S 3 T: . N R, E o W LrcelTai(Numbec y, Village, Township Of: Leg a Description: 1. No plumbing will be installed in the privy. 2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or holding tank exists, or a valid sanitary permit to install such a system has been issued. 3. A privy vault / pit shall maintain minimum setbacks as specified in Table 1. Table 1 Well Building Lake / Stream Additional County Setbacks Open Pit 50 Ft 25 Ft Min. 75 Ft Sealed Vault 25 Ft 25 Ft Min. 75 Ft 4. Privies for public buildings shall comply with ILHR 52.63, Wis Adm. Code. 5. Privies used for one- and two-family purposes shall be constructed in such a manner so as to exclude flies, rats and 'other vermin. Doors should be self-closing and vault ventilators should terminate at least one foot above the roof. 6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall comply the intent with ILHR 83.20, Wls. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code. 7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR 113, Wis. Adm. Code. 8. This agreement shall be binding on the owner, their heirs and assignees. This document shall be recorded by the register of deeds in a manner which allows its existence to be determined by reference to the property where the privy is installed. Printed wny~~1 s Na e(s) ka r S . r~ Subscribed and sworn to before me on this date: wner s g ture 4 /11v~~ Notary Public My commission expires on: SBD-6432 (R. 05/91) NOTE: This document was drafted by the State Department of Industry, Labor and Human Relations, Bureau of Building Water Systems. c J I i I ! u1 1 l Q ! ' Lill I L~ cJ / I J~ - 1f f