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HomeMy WebLinkAbout042-1016-70-120 Q c Q) °o M O N Q. O O C ' l~ O O O x F.0 C O Y - m O m i t o o i o i N N ~ N O N Z W C O C LL C O O O ~ C z z w o L Z y y 04 UJ CL m O z z O ~ N c ° y I N N ~ O m a) C, [ c LO N N o N d U) N O Z m z o 0 N Z o I C O a N co m E CD N d> o y - m d v a 'M 00 N U) T o o a D ~rl Z N> H F- H = O a 0 0 0 LL ry o a a a r a. g m I I. N p cn c rn 04 04 rn c N U N rn rn Q r o a M N O t-- r- 00 O O O CL N LO ~ N N ~ N m co ~1w C ~ 7 w O O :2 N C y N N O C O E ,n r 4 O O U i F- O 30 2 N C c a) O ,6 (D "t rZ O C O Lo 3 N N fr' m N • JV I~ > (0 L (6 (0 U C) 0 o C RI may/ °i df ~ IL EL L: CL r`iry E i c c V j FILtb AUG 2 21990► 3 JAMES O'CONNELL i Register 01 oeego C ER T I F I EO s, - S UR . V E Y M R Located in the SE 1 /4 of the NE 1 /4 of Section 7, T29N, R-18W , / -100th-ST Town of Warren, St. Croix County, Wisconsin. NE Cor. Owned by: Robert and Lucille Mello, Rt.. l,• R•oberts, Wi. 54023 Sec. 7 T29N North line of thee SE1 /4 of the NE 1 /4 ♦ / R 18W I07th N.80§48 19"E 640.3P' ' ~ N01°23'S5'rE - _ 4P7 4,4 251.9 318!8 6 .98 1326.82' AV E._ i0 49.43' N 89' 42' 10"W 423`89' 32.23 ° LEGEND 327..72 96.37,'-O~ Section corner monument I I 6 • 1 Iron 1L ® 7i- 1 LL ® ~f' I ~ i pipe fnd. 439,892 Sq. Ft. 197, 003 Sq. Ft. I 0 1"X24" Round (10.099 Ac.) (4.523 Ac.) I co iron pipe weighi g Including ROW Including ROW I a 1,68 lbs/lin. ft. 423,246 Sq. Ft-. 142,926 Sq. Ft. bl ~I ~ set. (9,716 Ac.) Excluding ROW ^.I wl a --t Fenceline Excluding ROW m (3.2$1 Ac.) a1 Lull LO (R) Previously n ~ I U)1 N recorded info. C WI of ~ o APPROX. LOCATION al to East line of OF PE RC TEST I I WI the NE1/4 I of Sec. 7. 13 eax.ings..reference I g to tine East-West rn in I Ouartex section N N line, previously m " Iee o' e4e recorded as o o N 89'06 39 7' M N90 00'00"W . W w Ni ~ ~ ~ of o u7 vj to Z~ !2 _ A A ~'9D N Certified Survey_ -jj Map t I V_ EIG 7. l 14J0 zl o ol.- - 71 Pape 2054 I al / of o ST M, lX coum'y z Z w, ~1 w WIMA Q•iF.IVE PARKS fli.ANNIN•. AND ZONING CC•AMV%M7. Lj o I LL. co I0) al z °0 a l of I (Y) - - 1 I 01 I W n W a ~eoeene~ioa y 3~,, a U o ~caCO/~s~ y' V o i0 2 s~ a I e ~ H:AF?81) VEY G. w o I~ NSON ° Z 91 w to cn SON 1S - C ~e il I .Ijas E1/4 Car. Section 7 4632.48 312.85' T29N, R 18W N 90'00'00"W 336.68' W 1 /4 Corner Section 7 UNPLATTED LANDS South line of the NE I /4 This instrument drafted by: HGJ 4901774 Vol. 8 Page 2261 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ~l~s.~1wY SECTION TN-R /D W ADDRESS ~h c C-Lcr~iyY~ 14tf- ST. CROIX COUNTY, WISCONSIN ~ Dom„ _ sS~P l ~ SUBDIVISION LOT OT SIZE :Z .S'PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7 Y4 r 70 OF to 1 l INDICATE NORTH ARROW BENCHMARK:Elevation and description: r-1-o ` ~s Alternate benchmark SEPTIC TANK:Manufacturer: &'I"'l`Cs Liquid Cap. wl Rings used:JQ-Manhole cover elev:l 3 Final grade elev: 1Q e / Tank inlet elev.: /0 2r 2- Tank outlet elev.: /o% Yt i No. of feet from nearest road:Front , Side , Rear Ft.~®~/ From nearest prop. line:Front , Side , Rear Ft. No. of feet from: Well Alm e , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE ~I PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front-, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length /0 9 Number of Lines:-.,/ Area Built S'~Ya~ Exist. Grade Elev./O 40 Proposed Final Grade Elev./©a,0 Fill depth to top of pipe: / No. feet from nearest prop. line:Front , Side , Rear ZFt..7,f0 No. feet from well:A' k< No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front Side Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: vt DATE: PLUMBER ON JOB: LICENSE NUMBER: A~4 7 6/90:cj L~S#r an artr rl7fustfy• 29.18 .100A IVAfitIt WAGE LOT 2 SYSTI`M 07TH AV County: Latch and Human Relations PR INSPECTION REPORT Safety and Buildings Division ST CROIX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 171515 Permit Holder's Name: ❑ City ❑ Village [ Town of: State Plan ID No.: RAYMOND, ON WARREN CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: l0 ~h, rtp r Description: 042-1016-70-120 ~ TANK INFORMATION " ELEVATION DATA A9200281 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0 Benchmark lr~~,.6 / b D, 6 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet /U )S TANK SETBACK INFORMATION St/ Ht Outlet o , i. Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air A j-,14 311 NA Dt Bottom Septic >17 -5' Dosing NA Header/ Man. y (P a 7,0 7 Aeration NA Dist. Pipe 7 9 ff , 5 Holding Bot. System q-7. PUMP/ SIPHON INFORMATION Final Grade 3, ~S /oo. o y Manufacturer Demand Model Number GPM I Loss Friction System TDH Ft TDH Lift Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width r Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J 6g DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O _n" CHAMBER , Mode Number: System: 7-/ujn wv X50 OR UNIT DISTRIBUTION SYSTEM Header/Manifold 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 11 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Tr nch Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) .w~ i 3 Plan,reieision required? ❑ Yes E] No a J Use other side for additional information. loy F J-1 Date nsPector's Signature Cert. No. SBD-6710(R 05/91) ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code CouN 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. Q Cheek ii re' vYion previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PR PERTY NER PROPERTY LOCATION 4, S T Z9, N, R E (orA62 PROPER O ER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE 1 PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ,7 A,7 u9~ S l F NEAREST ROAD II. TYPE OF BUILDING: (Check one) 11 State Owned VTOLWL AGE Q r O j!1 G El Public LJ 1 or 2 Fam. Dwelling-# of bedrooms :3 PARCEL TAX . NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo r 20 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. 2 'New 2. ❑ Replacement 3. ❑ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ SpecifyType 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ) 6 d d ,V Feet Feet CAPACITY VII. TANK in alions Total # of Prefab. Site Fiber- Exper. Manufacturer's Name Con- Steel Plastic INFORMATION New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank ~0 OD F1 F1 L1 I L1 H 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. nVq) PRSW No.: Business Phone Number: P ber's Name (Print): um er's Signature: (No Sta r/M 6 5' 'Plum is Addre (S et, City, tats, Zt Code): G~/ a L IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signat re( Stamps) pproved ❑ 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 j 4 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,'9enewal 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 1993 Wisconsin Act 410 included the creation of surcharges (fees) for a numl_:~:r of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring gr, iilot1wafer, ground., water contamination investigations and establishment oF'stand rd;. SBD-6398 (R 11/88) S T C - 100 This application form is 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/contractor,(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 Ronald Thomas Raymond and Kathleen Ann Forsythe Location of property SE 1/4 NE 1/4, Section 7 , T 29 N-R 18 W Township Warren Mailing address Not Assigned at present time. At present, owners live at 812 McCutcheon Road, Hudson WI and 824 Elm Street, Hudson, WI Address of site Not Assigned at present time. Subdivision name NA Lot no. 2. Other homes on property? yes x No Previous owner of property Rc)hprt and , i i Mello Total size of parcel 4.523 Acres Date parcel-was created August 22, 1990, certified survey map 461669 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes No volume 8 and Page Number 2261 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL 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 Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 483588 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded the office of County Register of deeds as Document No. a~~ Zd, n 4 C/. S' n ture of applicant Co-applicant Aae" of Signature D e 'f Signature a~ 1 z..oaima . tie................:.......: t F ,i ttKrr,,,Nww. w .te~aald..T..LZnoa~d..sod.~4Lhlesn ~ 13.1# y ~...a~«03AL. tAOiAti.... i, t.h.... - - 11tt411M a W+M "d~ is ............SI... CraiX-........C"Ift X Tax hr d hot. Tbat.part of SZ%N1% Sec. 7-T29N-x18W described as fo2lovs: Lot 2 of Certified Survey Nap recorded to -Vat* Is page 2261 as Doc. No. 461669. r This. homestead property. fill (i• rat) zwe"U" to warramiN: Existing highways, easements and rights of way of record. ua" this ! S 4-t I day of May. . 19 . - (SEAL) Robert L. Mello • Lucille C. Mello AQTtsATICATION ACKNOWLSD@Z+I1M' y '4h STATE OF WISCONSIN ms(s) _ • ~ St. Croix. X. attiw4tti irtstt. .aw of . it...... Personally- ravW-Ohe! 4 RQacrt..~+......',*.. F M~~,ls~. h11b , R.Ea 11fl~A I1TA'I•E BAR OF WISCONS11 li to no -to # :~Y r ctt ax I-A S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER- Ronald T. R ymodd and Kathleen Ann Forsythe address currently is 812 McCutcheon and 824 Elm Street, Hudson, WI 54016 qq~~a7rr~~er R ROSS Not adsianed at this time FIRE NUMBER Not assigned at this time. CITY/STATE Roberts, WI ZIP 54023 PROPERTY LOCATION: S_1/4 , NE 1/4 , SECTION 7 , T 29 N-R18 W TOWN OF Roberts , St. Croix County, SUBDIVISION Not applicable , LOT NUMBER 2 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 60% 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. 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 y the Wisconsin DNR. Certification stating that your septic h b n maintained must be completed and returned to the St. Croix C Zoning Officer within 30 days of the three year expiration d SIGNED : 1Ca DATE : _ '2y Z-' St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 L yt ~ asp ,fix ~ Iii FOoom PL.UNBLNG Licensed Pork Tester Plumber f F #r y t v sights Rosd R08EKYS. Mfls~%oNSIN 54023 phone 749-3656 ~1 / ~ ~ri✓dJf < ~.si v c '~s a ~.c/ "If S' I j ~tr~fNONG~ ~ 7 ho c ~ r ff3 i I ,5'c R le- Ad / _ Yo 0sS'u c+~ //cam, p I vym _ roc I I (,x earmer LO~ L%y~ ~4 t I (E v ,,ew ~ u << o REPT131• WARREN ST. CROIX COUNTY ZONING PAGE 1 08/24/92 08:07 REQUESTS FOR INSPECTION WORK SHEETS FOR: 8/24/92 AREA: MJ Activity: A9200281 8/24/92 Type: CONVSEPT Status: PENDING Constr: Address: WARREN 7.29.18.100A-20,SE,NE, LOT 2, 107TH AVE. Parcel: 042-1016-70-120 Occ: Use: Description: 171515 Applicant: RAYMOND, RON Phone: Owner: RAYMOND, RON Phone: Contractor: FOGERTY, DAVID B. Phone: 749-3656 Inspection Request Information..... Requestor: FOGERTY, DAVID Phone: Req Time: 10:08 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION TOIL R SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El / 7`(/~ 8% X 11 inches in size. C eck if rev sion to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO RTY OWNER PROPERTY LOCATION c fe'/4 '/4, S T , N, R E (o PROPERTY WN S MAILING RESS LOT # BLOCK # CITY STATE ZIP CODE PHONE NUMBER OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD r, D ~z ( ) State Owned ~ VILLAGE' ❑ Public L'S1 or 2 Fam. Dwelling-# of bedrooms JL PAR EL AQXF NUMBE (5) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ 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 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ 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 L`S 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 4/510 7X0 Feet Feet VII. TANK CAPACITY Site in alIons Total #of Manufacturer's Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 7~ Lift Pum Tank/Si hon Chamber E] El El E] -E1:14 1:1 VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu ber's Name (Print): lumber me!-(N 6 MF4MPRSW No.: Business Phone Number: Q < ~-S er's Address (Street ty, to, Z' ode m COUNTY/WPARTMENT USE ONLY L] Disapproved anitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Signature No Stamps) Approved El 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 Saritary 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. It. 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 prE:fix (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'h x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with cor plete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers, ae;;s, water mans/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas, and the lour}t',on Of the building served; B) horizontal and vertica' elevation reference points; C) complete specifications for pumps and controls; dose volume. elevation {~ifferences; friction loss; pump performance curve; pump model and pump manufacturer; D) crass secti;--n of the soil absorption system if required by the county; E) soil test data on a 115 foram; and F) all sizing information. i I GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 'Included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies rzo'lected through there surchargµs are 9a~.~~ f for Monitoring groundwater, grofjnc'- water contamination investigations and`establishroent r.~i' slan&ams. SBD-6398 (R.11/88) DAVE FOMM PLUMBIM U:enud perk Tes#K & Plumber #32 OM- ROBE phone 749'6 54423 / / 33~ `v~ Lrj+sr~ 27 ' gas K- ° r~ f r gSSatlwr /Od, O o boa k~ 14 ~s y7C'rt~i~ ~YPe ° P/w = F6s Z r St{ s~ ~ ~l n,- 7° r ~z3o %d r r i'3 _ ~H N~ 7fhJw4e_ ~ L I 1 " i 1 , ~ t 1 i 5_RC 4 aW_. • • y •v `(In