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004-1067-60-000
~g ~o Q o 3 0 3 0 p O 6 o e» O ua N N ao ao N c 0 a Q 0 ° w N o CD (n o m Ern- cm N n a0 ~ o a0i U 3 M M 4) Cl) N N w 7 O N N '°O O- y O. (D C.) -0 CD c h IO O N a N C~2 m N N > M O a C O' N 'O C N U N N Q, 00 0 S N y E m m N o Cw._ -0 ce) n > a m E CD Q) C) :3 o, N N a y o c a~Y a I alit (n n E 0 0) Z m° E o.~L w o o f h 3 m m E a o N O o o° a w E x E m N Cu Q -O C° N '3 N a C Eo 2 N LL O. N O` O_ U O O N 0 0 -0 7 c z a) mmo= c c Z rn E W y c z aNirn L m 0 LL C U. O O MN~>~N U. O 3 0 a o VoN 0. C ~5 -0 _0 N m m C 3 0 N ,O N O y N III N .O N U E O O Q y° o'er=-o Q iE E N a E Q 0 m= U O N (0 3 a III Z 1!1 N Li _ Z yj Lo W O C 0 O w y N N N Z N N 00 C14 am am am N H Z O - C ~ ~ ~ U I O Z d C C w V O .N. O y .U. O N Z V c 0 c c z N F- N N N N C y ` y N 0 N _ N ( 6 (U C LL N N C 0 .0 O) s • 2 O N (n p O Q Q O C N O C O N 'o 0 (1) Q Z (n Z Z co z 2 Z Z p O N LO z 00 N C N N m E a m v N w v i V) U) D N= y! 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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - CADY CHEESE FACTORY INC, DALE & WENDY MARCOTT DALE & WENDY MARCOTT CADY CHEESE FACTORY INC 126 HWY 128 WILSON WI 54027 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 11.186 Plat: N/A-NOT AVAILABLE SEC 28 T28N R15W BEGIN SE CORNER NE SE; Block/Condo Bldg: TH W 427 FT, N 295FT, E 295 FT, S 130 FT E TO SEC LN, S TO POB ASS'D WITH PARC Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 449B & INC COM 14 RDS S OF NE COR SE SE; 28-28N-15W TH S 105FT; TH W 1320FT TO 1/4 LN TH N 336FT TO 1/4LN; TH E 1155FT; TH S 231 FT; more... Notes: Parcel History: Date Doc # Vol/Page Type 08/05/1999 608093 1447/093 WD 07/23/1997 933/344 07/23/1997 581/152 07/23/1997 534/509 more... 2005 SUMMARY Bill Fair Market Value: Assessed with: 106866 1,087,600 Valuations: Last Changed: 11/09/2005 Description Class Acres Land Improve Total State Reason MANUFACTURING G3 12.680 26,800 1,120,500 1,147,300 YES Totals for 2005: General Property 12.680 26,800 1,120,500 1,147,300 Woodland 0.000 0 0 Totals for 2004: General Property 12.680 13,100 586,200 599,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM Specials: User Special Code Category Amount I ents Special Charges Delinquent Charges Total Special Assessments 0.00 00 0.00 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations ^ INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION PIT( wn of State Plan ID No.: Permit Hold r 's Name City ❑ Village C, e eke- e CST BM Elev. Insp. B Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septi Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake S NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Q ~ 0~ Bot. System Holding x/40 1 PUMP/ SIPHON INFORMATION Final Grade Man Demand Model Number GPM TDH Lift Friction stem TDH Ft Loss Forcemain Length Dia. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of T ches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manu acturer: SETBACK SYSTEM TO P/L BLDG WELL KE/STREAM INFORMATION Type O CHAMBER Moe Number: System: 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 Depth Over xx Depth Of xx Seeded/Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes No E] Yes ❑ No COMMENTS: (include code ddisccrepanc es, persoons present, etc.) Plan revision required? ❑ Yes 0 NO Use other side for additional information. 0 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION COUNTY ~ILHFR In accord with ILHR 83.05, Wis. Adm. Code St. oix Count STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than/7v 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S91-40620 PROPERTY OWNER PROPERTY LOCATION Cad Cheese Factory / Dale Marcott NE t/4 SE t/4, S 28 T 28 , N, R 15 XE (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Wilson WI 154027 715 _ CITY NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned O M TOWN _4 VILLAGE : H '1128" 9 Public 121 or 2 Fam. Dwelling-## of bedrooms 3 R El ~ TAX NU100-t-&6 M. BULDM USE: (If building type is public, check all that apply) V5d S s f ❑ rtpfNCe~'t~ _ - ~'t 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestaurafWW/Wning 40 Church/School 80 Mobile Home Park 12 El Service Station/Car Wash 5 ❑ Hotel/Motel 9 U Office/Factory 1130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.E1 New 2. U Replacement 3. ❑ Replacement of 4.E] 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 R 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 5, 450 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION N. A. N. A. N. A. N. A. N.A. Feet N.. A• Feet VII. TANK CAPACITY Site Exper in gallons Total # of Prefab. Fiber- . INFORMATION New istin Gallons Tanks Manufacturer's Name oncret structed Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank _ Lift P VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installatio h nsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' g . (N MP/MPASW NC,~ Business Phone Number: Jack A. Bowman 011 MP 5875 715 235-4634 Plumber's Address (Street, City, State, Zip 281q Knapp 1; - Men n i e 141 54751 IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (Includes Groundwater a e Issue Issuing A nt Signat tam Approved F-1 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 8 Buildings Division, Owner, Plumber LHF' SANITARY PERMIT APPLICATION - In accord with ILHR 83.05, Wis. Adm. Code COUNTY . St. Croix Count 77 STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than - eft,f 1,191-70 8% x 11 inches in size. ❑ Check if revision to previous application Il -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S91-40620 PROPERTY OWNER PROPERTY LOCATION .ad-; Clap-ese Fac'tcrY / Dale *tarcott NE % SE Y4, S 28 T28 N, R 15 7Cff or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # N. A. rL A. CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Wzisa!i WT 154027 715 1 11. TYPE OF BUILDING: (Check one) ❑ StateOWned CITY NEARE TROAD VILLAGE H n12g~- NUM O / ® Public ®1 or 2 Fam. Dwelling-¢~ of bedrooms PA E TAX g: SE: (If building type is public, check all that apply) a° Z Anembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Ree 3 Cwripground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/ 4 Church/School 8 ❑ Mobile Home Park 12 ❑ Service StattonIt ile 5 ❑ Hotel/Motel 9 12 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. ❑ 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 430 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 5,450 NT. A. N. A. A. N.A. Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank 7 435 7 , 1315 1 Wie,3pr Crmc;`e-to Lift P Ll El I El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instal lationof th onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber'e Signatu (N MP/MPRSW No.: Business Phone Number: Jack A. ^yo~►-man art} 5875 715 235-4634 Plumber's Address (Street, City, State, Zip Code): 2819 K4iap,.) St. 114--n nie X17 .'!7'=:1 IX. COUNTY/DEPARTMENT USE ONLY Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Agent gnature {N+a.$tam❑ Approved Given Initial Surcharge Fee) x 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 DEP.ARZ:ANIENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ADUSTRIIr, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ OT NO.: BLK. NO.: SUBDIVISION NAME: NE 1/4 SE 14 28 /T 28N/R15£' (or)W Cady N. A. N. A. N. A. COUNTY: MAILING ADDRESS: St. Croix Cad Cheese Facto & Dale Rt. 1 Wilson WI ry 715)772-4470 54027 factor (715)772-4218 USE Marcott DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DES RIPTION: New ROFILE DESCRIPTIONS: A I 115N TESTS: ©Residence 3 and Cheese Factory Replace July 8, 1991 omitted RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) El S ~ ❑ S RU J ❑ S ®U ❑ S EU S ❑U Holding Tank If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: N.A. PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) tey~ 7/3 --,*:1( /1 hCri~ ri~ ><S IGyR 5/c s~ B-l. ~}5 r, one 5 I.. ask ~t -t- Vc tr of s B- g Eni"Olek 1 N t1. no ~1 k, C3 „ 1 i t( Q i r U B- PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES E t NUMBER INCHES AFTER SWELLING INTERVAL-MIN. -PERIOD 1 PERIOD 2 PERIOD PER INCH P- P- Ornithed- soil bor ngs indicated that the so 1 was not sni ~7e for any P- P- P- P- PLOT PLAN: 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 slope. uoilonilsuoo Aue to IJels 9141 01 Loud p9lsod pue pourelgo 9q Isnw liwied Ajepues aU1 i!w'9d a u!elgo of japio u! Ai!jo141ne leool aleudojdde ayl of pell!wgns aq lsnw uo!leoildde l!wj9d a pue wolsAs o6emes 91enud 9141 joI sueld to l9s eloldwoo V 93uenss! I!wied oI Joud ple!1 e14I u! Isel I!os s!yl to uo!Ieoyuen Isonbei Aew lu9w1jedaO aw jo Alunoo a141 liwied Aiel!ues a 6uunoes ui dels lsl!I 9141 Si Nodal lsel I!os s!141 :U3NMO 3H1 Ol z - U Bowman Plumbing, Inc. Jack Bowman - Proprietor Master Plumber No. 5875 2819 Knapp Street Menomonie, WI 54751 (715) 235-4634 FAX (715) 235-3650 PLOT PLAN/115 Cady' Cheese Factory lof , h Dale Marcott NE4SE4S28T28N/R15W St. Croix County • Q" S ~dP bA LEGEND Borings dug with p"k;~5 ~.~0.~•~ 1zg backhole e~~ q"A°` 5 - App. 5 acte arcel 13w11; ~pl4 D"tI~p 1 r ~lk_ - ' inn .a,• 1 c Ate. 0 ~ siOdL - retta A. La e CST 3719 m J N All- Route ' ey 1 Iirahmer Bowman's Plumbing ltotu Wilson,.WI 54027 Jack Bowman - Proprietor St. Croix County Master Plumber No. 5875 Cady Township 2819 Knapp Street r NEkSE!4S28T28N/R15W Menomonie WI 54751 SYSTEM ELEVATION: 94.6' hack A. Bowman MP # 5875 (715) 235-4634 CST # 2538 sd~oc O ? V I - I Fj~(.~(/ . 7CG ~4t ~ I ' i O ~ 5/yre r V o (i YO 100-4lC 1-4,4 ~r ~ 4 ' ~vf c 7 - I" ce~f v v 'T T. V ~ ~2 CaG~ C ~~e~s~ el~leese SAFETY & BUILDINGS DIVISION State of Wisconsin 9 1Q Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL Western Regional Offi 2226 Rose Street N i LaCrosse, Wisconsin 03 op~ C, 0,P Cb 0 BOWMAN PLUMBING INC Owner: DALE MARCOTT S ~~~cF 2819 KNAPP RR 1 £ MENOMONIE WI 54751 WILSON WI 54027 RE: P1an.Number: S91-40620 Date Approved: August 19, 1991 Gallons Per Day: 1,140 Date Received: August 2, 1991 Project Name: CADY CHEESE FACTORY Location: NE,SE,28,28,15W Town of CADY County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the t construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary' permit is obtained, it will expire the day the initial sanitary permit expires. r The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT PETITION - REPLACEMENT HOLDING TANK - The plumbing for this project discharges to a private sewage system. The approval covers only the domestic/sanitary wastes that are directed into the private sewage system. The Department of Natural Resources must be- contacted in regard to the treatment and disposal of all industrial wastes including those combined with domestic/sanitary wastes. The discharge of hazardous wastes to a private sewage system is prohibited by state and federal regulations. Accidental discharge of any hazardous substance to a private sewage system must be reported to the Department of Natural Resources or the Wisconsin Division of Emergency Government. i S110 6423, H. 01/911 r ! SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations BOWMAN PLUMBING INC Page 2 Inquiries concerning this approval may be made by calling (608) 785-9348. Sincerely, t GERARD M. SW i Section of Private Sewage Division of Safety and Buildings PPP039/0009n/ 2 cc: DALE MARCOTT X Private Sewage Consultant a S r J. t t t i i t `(4F Lkk' (F( t tt F ry G GI t 5j SHD (W23 iN.01/911 ~`j SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Bog 7969 Madison, Wisconsin 53707 State of Wisconsin Department of Industry, Labor and Human Relations August 16, 1991 DALE IiARCOTT ROUTE 1 WILSON WI 54027 Petition No. S91-40620-P Dear 11r. 'Harcott: Re: Cady Cheese - Factory Private Sewage System NE,SE,28,28,15W Town of Cady, St. Croix County, U1 Your petition for a variance to section ILHR 33.18 (7)(a), Wisconsin Administrative Code, has been reviewed. The petition has been conditionally approved. The condition is that the holding tank vent shall be offset to be 25 feet from any door, window or fresh air inlet. The rule being petitioned requires that holding tanks shall be at least 20 feet from any part of a building. The variance requested was to install a replacement holding tank 10 feet from an existing storage shed. All of the data and statements subreii tted on behalf of the petitioner were considered. This variance is specific to the subject petition and cannot be used for any additional modifications. Sincerely, R `h~ d %VAetli""t ecDirector, Office of Division ~ Codes and Application (603) 266-3080 RM: GMS : 588WPP3 cc: Leroy Jansky, Private Sewage Consultant - District 6, Chippewa Falls Thomas Edelson, Zoning Administrator - St. Croix County Bowman Plumbing, Inc. SBD 692841. 01191, i - - "'are 2 Of HOLDING TANK CROSS SECTION ~91-4QQ2Q (nn scale) WEATHERPROOF JUNCTION BOX HIGH WATER WARNING DEVICE ON 8' POLE OR IN/ON LOCKING DEVICE AND -7 BUILDING SERVED WARNING LABEL AT COVER CONDUIT 12" MINIMUM - 4" MINIMUM MANHOLE - MIN. 2" CAST IRON VENT WITH MIN.24" ID GRADE RETURN BEND OR 4" CI WITH ; APPROVED VENT CAP. 25' MIN. FROM DOOR, WINDOW OR FRESH 18" MINIMUM AIR INLET f LEAD JOINT AIRTIGHT SEAL / HIGH WATER ALARM SWITCH---- BLIND C.I. PLUG DEPARTMENT APPROVED JOINT WATERTIGHT JOINTS ARE INDICATED BY UNLABELED ARROWS *PROVIDE APPROVED PIPE FROM INLET TO 3' BEYOND EDGE OF UNDISTURBED SOIL SPECIFICATIONS TANK MANUFACTURER: Wieser Concrete Pr TANK CAPACITY: 7,436 GALLONS, py2Cd~n~ 0 75 5/8" height 59" below inlet A V 238" lenght (19.831) 142" wid 83 ) 0- HUWypN RELpT10 Rl , LABOR AN LD4WGS DCPARZMF~ F ~N011S'f` iGN Eta PLUMBER/DESIGNER SEL COB SIGNATURE: r ~a^ LICENSE NUMBER MP _5eijS -"64i DATE: t` - 2q - _ 20 2112" 21/!" a„ , 1 v1r ~ =B- C t, 14, s 3 fi ASE&~ 1rOP:~ Cast Intergraliy WthMall ~ A C7Y s -T'Wi~Septic~`6,01a Gt~ilons~'~ 4} 1t Septa 8,010 Gallorl - j• olding x7,436 Gallons ~1 ENFORCEMENTrr r SideWalW 518" Rebae & ,ilYImMesh 6 x 6110 Gaugu,,, Cover and Base - $14' rt Reba C h E, r n~ z 3re,Mesh 6 x.6110 Guage:;k ~S, -pIMENSIONS ~ t. r`w Walls; 6 Ribbed Length,-A 9, 1 ottom Ribbed .a Width 10• Coyer. 8'! Ribbed ~1►f° BeloW nlet 9' ~elght ;75-5/8 ' _MN Be1vTt IrtCet A 59 . . Man . T JOUS`USES SE" ~ iG~#QU1~0, qu it IQ SECTIONAL TANK MIESER RT.2 110) BOX 14 MAIDEN ROCK, N 54750 - 715847.2311 A-M r Bowman Plumbing, Inc. Jack Bowman - Proprietor S91-40620 Master Plumber No. 5875 2819 Knapp Street Menomonie, WI 54751 (715) 235-4634 FAX (715) 235-3650 Cady Cheese Factory ^ ` - Dale Marcotf NEkSEkS28T28N/Rl5W \ Slap 6 St. Croix County • Pro il©E Fars-r t'EC't'iON AS PEEZ cxy~cca~o~~ tJ / e i~ 1uhe..~j j ►ewl.r~eo~k y~- `it3 XSO LEGEND s toy I I 11 9y3~e gat 3~.,k ,~Kog.~ Borings dug with backhole App. 5 acre_ parcel Y~TEM J S n1o il" - 40' , Lfw AN RE~,pS10NS T LABOR AND INOUSYRSA D DING9~ r ~ ~ Lhr..~a~--y pSPA V1S10N 0 A ~ b ~ , b - - - - - -a SEE CORR E SI?fit \,n S.islol.. ack A. Bowman MP 5875 1"s ^ mb"MV4 TOE EXlSYtMG Str`c J SYS'ft=+~n,AS lLl►t~ 63,©3 P-) - PE'T'ITION . . ~1 -40020 Wisconsin Department of Industry, Labor and Human ations OFFICE USE Amount Paid ONLY Safety and Buildings Division Petition No. ONLY 201 East Washington Avenue, P.O. Box 7969 Receipt No. Madison, Wisconsin 53107 E-Number 608/266-3151 Name of Owner/Petitioner Building or Project Agent, Arc i.ect or Engineering Firm ~lel•cott _ N.A._ Bowman Plumbing Inc. Company Tenant Name, if any Street & Number Cad Cheese Factory N.A. _ 2819 Knapp St. Street & Number Location, Street & Number City State Zip Code Route 1 _ N.A. Menomonie, WI 54751 City State_ Zip Code City County Telephone Number Wilson WI 54027_ N.A. (715)235-4634 Telephone Number Plan Number, if known Name of Contact Person 715)772-4470 N.A. Loretta 1. The rule being petitioned reads as follows: (cite specific rule number and language) TT-&M 83-1R - 3 (7) i nGta 1 1 ai- i nn _ ( a )Ix--na _j on , Tanks shall be located in accord s.ILHR 83.15 (4) (a) except the tanks shall be at least 20 feet from any part of _ viicding. 2. The rule being petitioned cannot be entirely satisfied because: The site is totally populated with buildings and the vehicle traffic makes it unacceptable any where else. 3. The following alternative(s) and supporting information are proposed as a means of providing an equivalent degree of health, safety or welfare as addressed by the rule: Tt_is prrMased the holding tank so be located 10 feet from a unhabitable shed so being out of the direct line of traffic Note: Please attach any pictures, plans, sketches or required position statements. VERIFICATION BY OWNER - PETITION IS VALID ONLY IF NOTARIZED AND ACCOMPANIED BY REVIEW FEE See Section Ind 69.15 for complete fee information Note: Petitioner must be the owner of the building or project. Tenants, agents, designers, contractors, attorneys, etc. may not sign petition unless a Power of Attorney-is submitted with the Petition for Variance Application. Dale Marcott being duly sworn, I state as petitioner that I have read the foregoing (NAME OF PETITIONER, Please type/print) petition, that I believe it to be true and I have significant ,pl 4 rights in the subject building-,or project. _ 5 cribed sw n to before me this date: Si ature of Petitioner 0 0 T A R e v y~pRrnBs; ip~e pi s: Notary Public (r t SR-8(R.09/88) Or wts°°~° Bowman Plumbing, Inc. Jack Bowman - Proprietor Master Plumber No. 5875 2819 Knapp Street Menomonie, WI 54751 (715) 235-4634 FAX (715) 235-3650 Cady Cheese Factory Dale Marcott NE4SE4S28T28N/R15W St. Croix County X99 FAX J ck A. Bowman MP 5875 f f Bowman Plumbing, Inc. Jack Bowman - Proprietor Master Plumber No. 5875 2819 Knapp Street Menomonie, WI 54751 (715) 235-4634 FAX (715) 235-3650 Cady Cheese Factory Dale Marcott NE4SE4S28T28N/R15W St. Croix County INDEX PAGE Sizing of holding tank 1 Holding tank cross section 2 Sectional tank Plot plan 4 A UG - 7 199 Holding tank.-agreement 5 Holding tank servicing contract 6 Petition for variance application 7 Percolation tests 115 8 Plot plan/115 9 Ja A. gn MP 5875 Bowman Plumbing, Inc. Jack Bowman - Proprietor Master Plumber No. 5875 2819 Knapp Street FLAX - 9, Menomonie, WI 54751 (715) 235-4634 FAX (715) 235-3650 Cady Cheese Factory Dale Marcott NE4SE4S28T28N/R15W St. Croix County I SIZING OF HOLDING TANK i I i Employees 32 X 20 gals = 640 gals Floor drains 1 X 50 gals = 50 gals Total 690 gals 690 gals times 5 day holding capicity 3,450 gals Plus the 3-bdrm home = 2,000 gals 5,450 gals require / proposed 7,436 gal holding tank 91-X40620 QUG _ 7 199. ~s~s • HOLDING TANK SERVICING CONTRACT tract Date July 24, 1991 This contract is made between the - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Ping Tank Owner(s) Name(s) - and i Pumper's Name Dale Marcott Steve Wold acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) NE4SE4S28T28N/R15W he owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality'', which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and vith'the County of St. Croix -he owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to )nter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access oad or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay he pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. "he pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. %dm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees o include.the following in the semiannual report: i. The name and address of the person responsible for servicing the holding tank; The name of the owner of the holding tank; The location of the property on which the holding tank is installed; f. The sanitary permit number issued for the holding tank; 3. The dates on which the holding tank was serviced; . The volumes in gallons of the contents pumped from the holding tank for each servicing; f. The disposal sites to which the contents from the holding tank were delivered. "his agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, he owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality tnd the County named above within ten (10) business days from the date of change to this service contract. ier(s) Name(s) (Print) I Owner's Signature(s) I Dale Marcott I ,1 Su ribed and sworn to before me on this date: I sal ` ~ I per's Name (Print) I Pumper's Signature Notary Public I My co ssion a Aires: 00 BO(A 0,000, Steve Wold •••"••••••;,"~'ifi iper's Registration Number + Urw -7574 (R 09/88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations to ~Doccy~ ent No This space reserved for recording data HOLDING TANK AGREEMENT Agreement Date i This agreement is made between the Jul Nr -2►-1cI91 County or Local vernmental Unit - I Holding Tank(s) Owner(s) St. Croix I Dale Marcott I (Called MunlcipaNly below) We acknowledge that application is being made for the installation of (a) holding tank(s) : n the following property, (Provide legal land description:) NE4SE4S28T28N/R15W Return To - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage Also. the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code. or Ch. 145, Stats. As an inducement to the County of St. Croix to issue a sanitary permit for the above described property. we agree to the following 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14. Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Slats. 2 Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4 The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) (Print) I Owner(s) Signature(s) I S scribed and sworn to before me on this date: Dale Marcott ~•e e Municipal Official Name (Print) I Municipal Official Signature Notary Public TcRom iss n expires: Ernie Ellefson~7ir / vlunicip I Official Title (Print) I Jb B 1. 3BD-6123 (R. 10/ 8) This instrument was drafted by the State of Wisconsin Department of I sh, bon and Hu r1~e ions. r4T foF w>IS°°~~ ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE rY"TPj 911 FOURTH STREET • HUDSON, WI 54016 _ (715) 386-4680 August 5, 1991 Bowman Plumbing, Inc. 2819 Knapp Street Menomonie, WI 54751 Dear Sir: I'm returning the Sanitary Permit Application Form for Cady Cheese Factory/Dale Marcott, because the form needs to be signed by the plumber before I can issue the permit card. As soon as you return the permit application form, I can issue the permit card.and send it to you. If you have any questions, please feel free to call our office. Sincerely, Jackie Stohlberg Secretary jrs cop . F 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 Dale Marcott Location of property_jM_1/4 SE 1/4, Section 28 , T_22_N-RAW Township Carly Mailing address Route 1 Wilson, WI 54027 Address of site Same Subdivision name N.A. Lot no. N.A. Other homes on property? X yes No Previous owner of property - Total size of parcel App. 5 acre Date parcel was created Sept 1978 Are all corners and lot lines identifiable? xx Yes No Is this property being developed for (spec house)? Yes ___No volume 581 and Page Number 152 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. 351651 , 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 in the office of County Register of deeds as Document No. 351651 'i- SignatulFe of applicant Co-applicant ~a 9 D e of Signature Date of Signature :-A- DOCUMENT NO. I j QUrr CLAIM DEED i `lo.`l 581 STATE BAR OF WISCONSIN -FORM 3 M H l ~,J L.~ ~ TNIB SPACE RESERVED FOR RECORDING DATA 351651 -I NORMAN MARCOTT and DOLORES MARCOTT, individually li REGISTERS OFFICE ST. CROIX CO., WIS. and as husband and wife • Recd. for Record this 13th quit-claims to _-.-CADY _CHEESE FACTORY----- RYt INC.• day of_ g__ __p+- A.D. 19_78 at 8:30 a M. Regis er of Nds the following described real estate in S County, _ State of Wisconsin: RETURN TO The South 10 rods of the East 10 rods of the Northeast Quarter of the Southeast Quarter (NE14-SE'S) and the North 14 rods of the East 10.rods of the Southeast Quarter of the Southeast Quarter (SEk-SE114) and commencing 8 Tax Key No rods West of the Southeast corner of said NE's-SEk; thence West 295 feet; thence North. 295 feet;.thence East 295 feet; thence South 295 feet to the place of beginning, all in Section Twenty-eight (28), Township Twenty-eight (28) North, Range Fifteen (15) West, except real estate deeded to the State of Wisconsin for highway right-of-way as described in the deed recorded in the office of the St. Croix County Register of Deeds on March 10, 1976 in "534", page 509, Document No. 331905. TRANSFER ~ ded FED is not This homestead property. IX Sept* 7th Dated this . ~X day of , 19._ 78 SEAL ...............................•------.._._.._._....-----------------(SEAL) - * . Norman Marcott - - (SEAL) ...,,7._,?2A C4t.7Z. ..(SEAT.) Dolores Marcott * • • '~i ,~.1 yr,'` u: AUTHENTICATION AC,ENOWLEDCIMEN3'f~ ^!/1RY '„'~}i,:^ Signatures authenticated this day of STATE OF WISCONSIN ..................................119 as. Pierce -•--•-........_•------•----County. Personally came before me, this 7th........ day of Sept. .T-19.73- the above named ...Norman.-Marcott * TITLE: MEMBER STATE BAR OF WISCONSIN asd•AQ1Qxes--MaxrQtt......................................... (If not, . - authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY to me known to be the person ..5........ who executed the foregoing instrument and acknowledge the same. Attoxney_.. CCLr_1_isa..V__.,1enaen Beverly Brune Notary Public ...Pierce Wis. (Signatures may be authenticated or acknowledged. Both .erect GjOe are not necessary.) My Commission is permanent. (If not, state expiration The use of witnesses is optional. date: 19.........) j1iA:irj-Ptlrtrc-,-Pierce-C,o,,-u'lls ~tv "Ommissioa cxpir" Oct. 28. 1979 *Names of persons signing in any capacity should be typed or printed below their signatures. QUIT CLAIM DEED JTATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 3 -1977 Milwaukee, Wis. (Job SSI") Form -ST C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Harvey Brahmer TOWNSHIP Cady SEC. 28 T 28 N-R 15 W ADDRESS Route 1 ST. CROIX COUNTY, WISCONSIN Wilson, WI 54027 SUBDIVISION N/A LOT N/A LOT SIZE es- PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM q I I ~ la I I~ 00, J 2mo INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Scn~~,, ,;y pu,r Zkee /ee' Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer:Midwest Precast Liquid Capacity: 1,000 gallons Number of rings used: 2 Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number_of feet from nearest Road: Front,0 Side 0 Rear, O feet From nearest property line Front 10 Side,O Rear, O feet ,~p® r building: 15, Number of feet from: well ? (Inc,lude this information of the ahove plot plan)( 2 reference dimensions to septic tank) SFF REVERSE SIDE ~ -z PUMP CHAMBER s Manufacturer: Midwest Precast Liquid Capacity: 750 gallon Pump Model: doEf YG Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: 5-4P Alarm Manufacturer: Alarm Switch Type: -_1 Zi= c<i2r _4r - Number of feet from nearest. property line: Front, O Side, Q Rear, 0 Ft. ys ' Number of feet from well: ~Uf /Jlvs rrc/r Number of feet from building: 3 ` (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: 1a?' Length:~~. Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 Pt. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: "'T"'2® Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 NE14, SE~4,S28,T28N-R15W IN CONVENTIONAL ❑ALTERNATIVE Sfate Plan l.O. Number: 11f assigned) Town of Cady O Holding Tank ❑ In-Ground Pressure ❑ Mound HWY 128 NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE to_9o. 7 Harvey Brahmer Route 1 Wilson WI 54027 BENCH MARK IPermanem reference poim) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber MPlMPRSW No.: County. .Wary Pe-1 Number: [Jack A. St. Croix 102779 Bowman SEPTIC TANK/HOLDING TANK: MANUFACTURER . JLIQUID CAPACITY . TANK INLET ELEV. . TANK OUTLET ELEV.. WAR DING E LABEL LOCKIIDENG COVER O IDEO: PROVD a l If YES ONO OYES ONO BEDDING DING. TO FRESH ALARM IVENT : VE NT D IA VENTMATL . HIGH WATER FEET FROM ROAD O 1PROPERTY WELL. BUIL AIR INLET NUMBER OF LINE ~ l OYES ONO OYES ONO NEAREST DOSING CHAMBER: WARNING MANUFACTURER JBEDDING'. LIQUID CAPACITY 1PUMP MODEL PUMP/SIPHON MANUFACTURER PROVID OLABEL PROVIDEDOVER OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA L. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER 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: WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER IN SIDE DIA -PITS LIQUID BED/TRENCH TRENCHES. MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH IDISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPE PTV WELL BUILDING VENT TO FRESH BE ES ABOVE NLET LOW PIPE COVER. ELEV INLET ELEV. END. PIPES FEET FROM LINE. AIR I NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ❑N~ SOIL COVER rexruRE PERMANENT MARKERS OBSEHVATIONWELLS DYES ONO OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL JOD111D EDED MULCHED CENTER. EDGES. DYES ONO SE OYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING GFi AVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.'. ELEV.. DIA. ELEV. PIPES DIA.'. ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS OYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LINE PROPERTY WELL: BUILDING. FEET FROM 0 $S DYES ONO DYES ONO NEAREST 5 q 6, Sketch System on Retain in county file for audit. Reverse Side. TITLE SIGNATURE. + Zoning Administrator DILHR SBD 6710 (R. 01/82) SANITARY PERMIT APPLICATION COUNTY LHR In accord with ILHR 83.05, Wis. Adm. Code St. Croix STATE SANITARY PERMIT Boa y 17 -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES D< NO PROPERTY OWNER PROPERTY LOCATION Harvey Brahmer NE '4 SE '/4,S 28 T , N, R r) W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Route 1 N/A n/A N/A CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK Wilson, WI 54027 715 772-4428 VILLAGE: Cad HWY 128 II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public (Specify): III. PU F APPLICATIO eck only one in #1. Check 2, 3 or 4, if applicable) IIC~II-s ~ 1. ~~1 New b ❑ Repl ent c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an Syum- system Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. M Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding C. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. ❑ seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Class 1 410 480 4 Feet R] Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strCucted Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank 000 1000 1 Midwest Precast Lift Pump Tank/Si hon Chamber 750 ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's n re: (No St MP/MPRSW No.: Business Phone Number: Jack A. Bowman 5875 1 _ Plumber's Address (Street, City, State, Zip Co Name of Designer: 2819 Knapp Street M omonie, WI 54751 VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST Jack A. Bowman 2538 CST's ADDRESS (Street, City, State, Zip Code) Phone Number: 2819 Knapp Strppt MI-nnmonip, WT 94751 715 235-3650 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved I itary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Do-co rcharge e Adverse Determination a!~.0 ~'o-19-g7 ~xC~t X. C MENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING IA SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill GroundlatatBC - included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's a can effect groundwater. The surcharge took effect on July -I, 1984. All of the water that buried Treasure t is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are creditE!d to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, _ DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 N WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE 1/4 SE 1/4 28 /T 28N/R ) W Cady I N/A N/A N/A COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: St. Croix Harvey Brahmer Route 1 Wilson WI 54027 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS. PERCOLATION TESTS: 5dResidence 2 N/A [K]New ❑Replace (September 15, 87 September 1 7 RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: IS YSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) a s ❑u ® S ❑U ® S ❑U ®S ❑U ❑ S ®U :Conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 72 97.0 None ) 72 6" BL ts, 20" Gray sil, 46" Y & Orange med sand B_ 2 42 93.4 None 15 6" BL ts, 9" BN sil, 27" mott clay g_ 3 72 96.6 None ) 72 10" BL ts, 12" BN med sand, 50" Red sand & Gravel B_ 4 72 96.6 None ) 72 10" BL ts, 12" BN med sand, 50" BN med sand & Gra el B- 5 72 96.0 None ) 72 10" BL ts, 10" BN med"-sand, 52" Red sand & gravel g_ 72 97.0 None ) 72 6" BL ts, 12" BN med sand, 54" BN med sand & grav 1 B -7 70 97.0 None PERCOLATION TESTS 10" BL ts, 10" BN sil, 50" Red sand & Gra TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P_ 1 30 None 10 3 21 2 Class 1 p- 4 24 None 10 312 2 '2 Perc P- 5 24 None 10 7 7 51 Rate P- P- P- PLOT PLAN: 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 slope. SYSTEM ELEVATION 94.6 01 3 LOD E E 3 o - ` . a.. _ _ z _ _ _ _m_.._. W.. 17 r , ( E e <74 E 3 f~ 1_O(Lc - 3 r 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Jack A. Bowman d/b/a BOWMAN PLUMBING September 16, 1987 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 2819 Knapp Street Menomonie 111 54751 253% 1715-236-3650 CST SIGN E: v DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequaoies 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 Harvey Brahmer Location of Property SE, Section 28 , T 28 N - R 15 W Township Cady Mailing Address Route 1 Wilson, WI ''54027 Subdivision Name N/A Lot Number N/A ' Previous Owner of Property Total Size of Parcel r'eS Date Parcel was Created .9 V0 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes / ~ No Volume 791 and Page Number 524 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION I (We) eeXU6y that a t statements on this 6onm cute true to the beat o6 my (our) k.now•etedge; that 1 (we) am (aAe) the owner (6) o6 the pnopen.ty des cA bed in thiA in6o4mati.on 6o4m, by viAtue o6 a wahAanty deed heeonded in the 066ice o6 the County RegiAten o6 Deeds as Document No. 42040077__; and that I (we) p4e6 entt.y own the proposed 6.c to bon the sewage diApo6EF6 ystem (on I (we) have obtained an easement, to nun with the above duc i.bed pnopenty, bon the con6t4ucti.on o6 6ai.d system, and the same ha6 been duty heeonded in the 066ice o6 the County Regizten o6 Deed6, a6 Document No. 430407 SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED THIS SPACE RESERVED FOR RECORDING DATA f DocuMENT No. STATE BAR OF WISCONSIN FORM 1-1982 430401` ; WARRANTY DEED Bou 791 PA-E524 II REGISTERS OFFICE It This Deed, made between Ha-vey._Brahmer__and............... ST II , CROIX M W., Wtsi -------------Doa..Brahmer,__.husband.-and._wife_.and__each..in..their. ( I own_.right Reed. for Record This 22nd t Grantor, j daq of Sept: A. D. 19 87 and ------------------Cady_ Cheese Factory, Inc., a Wisconsin Co ration ( : 25 P l - Grantee, ! R 1• DnMe Witnesseth, That the said Grantor, for a valuable consideration...... I ---------Seven- Hundred -and, -~la -100--Ballar-% --X700.00 _ I __.__Ste ~olX RETURN TO conveys to Grantee the following described real estate in i i J County, State of Wisconsin : Commencing 40 feet North and 10 rods west of the southeast corner of Section 28, T wn 28, Range 15 Tax Parcel No------------------------------------j West, thence 231 feet North, thence 262 feet West, thence 231 feet South, thence 262 feet East to place j of beginning. I ~j . s I V FEE; I ~ I It it This i.$.not-------- homestead property. (is) (is not) I i Together with all and singular the hereditaments and appurtenances thereunto belonging; And )3arvey Brahmer-and DOra_Brahnler-------------------------------------------------------................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except j and will warrant and defend the same. u Dated this /.=3. day of Nov2niher• 19.85 {I ✓ M" --------------------------------(SEAL) - (SEAL) j is * Hax-V-P-y Brabmer (SEAL) X6'1 (SEAL) ------(SEAL) - Dora Brahmer * ~j I AUTHENTICATION ACKNOWLEDGMENT Harve BrahMer and Dora It Signatures STATE OF WISCONSIN I SS. Brahmer Pierce Count j County. authenticated this ..day of November 85 19 Personally came before me this 1-------- day of September , 19A7 the above named I Dor . . 4hmex--- xed Jla .vey._Bxabmex--------------- !I *----------Robert R. Gavic TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ,•~r authorized by § 706.06, Wis. Stats.) to me known to be the person ...____41exeoutpd,the foregoing instrument and acknowle dge; the same I; THIS INSTRUMENT WAS DRAFTED BY R obert_.__avic - - * Meri ee J. Nestrud ~i r;_ - VX]g_ Vc711eY_ f. Notary Public Pierce.-- Coun(3~,l j (Signatures may be authenticated or acknowledged. Both My Commission is permanent (if n4"~jCate exiiyt~on," it are not necessary.) (i i date: ,...December 1Z. r ) ( *Names of persons signing in any capacity should be typed or printed below their signatures. ~ ~E 11 J! H.C.MillerConV" M STATE BAR OF WISCONSIN w ® FORM No. 1 - 1982 Stock No. 13001 LADY. T.28N--R.15W 23 SEEHPAGE J7 / Ral chard U C/, s H/,cer • Lest r /vane o t //nn Lois r'/Y s ~ E e. h fL and y tltl y Q y ~C • 'ec• gst y Leer O'Meo" Shack/eton ~a „4 c vtl B° ' B° Ba CO~C ~UQ CV n °au/, e Rena dJ 1 E/df,i NN Nato/d t F~ tl y b E V cSa cc ri. 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VV0 zro. 7s Ti:»,» /ym lane • : slbnce tj ~1 h on „ Bo ,sb.> Bo //~nyboc /`>o a y;1 0 Uo 9 e,LO Lcana rd• Ke n_ ant t7or orct e's.n- Dtv7a/d La ✓~r/7 E-~ gor •l •Y~ N eth rt 6 FiGUices • c~ e ~ yV p E~ V O/Bso°n Wan`y N ]ZIP L. //7 BO a y/e a0 0 s nBo S s 79 ds Son No7er~/d 0 5 La,>•,b • ph Tiinm, eta/ Tiinm 99.`1 f3/eyen Bo BO • BO AM R/ DE 90 OA R/DC w s • O. Tiea /o yam, h ao ao Richard F f ,god 1P anne % f /U~ b Fb F Tieo aue- Je 9 Strz~k 1Jnn rTacohs • Timm °i ,g we// 77 Bo Bo ~L. E~ Bo h'ampton ova fE/eano>~ /ao e O/ion Thomas G. zo_n a_n 6 zoB \\l~ (Tarries f a5°pp^^Y 223.92 f~,nR s~ N EIJO~o cs ,e iri Mo/danhau- ott Do6-6 o/e- c'- f[rif MQ'fo so S>`cin9er2 b /ud • Bo 9° ,to B I _ Oti C7ordon ~D ~ ~,auc /e Kc/>ncth • J° Th J /V t tzar n. { MRCVe/ p a d Paa- //6 l Cherr:e G \ ,y c err C7e zao -..8/ W an 7 y 79 ;7r /9rohmer J sch - T mm ! ,5' 23 1 a` . • .a.~' Ba • N p~ ~ ~ .Ro ~ 0 ~ 0 n ://ay' f .z t\ ~no/ /zo . Hacuny fora%df .9/an "1 , 0 p U tl~ Ba Minnie b\ n zoo.BB P .9 0 son so t.D E/~GC cth Ti,nm 410 7 0 \ V .~¢do V Q~ 1 a//fY' p 4o :ta/ C /9rahme ~9 `7S•i ~p UJJ ~OJ • 41 c'3/'/ w7/iam O. 1 • . • / • • 29 • C • Nei , s r7a :9 ~ b ~ L /o f • t3 C 0 Mar aret /ya td .6rahme/' ,,Zabe/M~yyy C~ tl koe%,E- h'e'/en Lle~n/s 4 Cafh.rine C l 0 KO'fTan _ 7B. 3z /Qichardso// y,~ ° b tl\0 0 F~ -U ° 9o e%' 4o Weber l V zoo a Nar ucy ~4 d\ tl 0 5\ F/anc/s N iao ~ v i ~ d z~°~7°s F /46 Jo Ce `L \ 0 A GJC~{//Y~ 235.,5 ,pon XI. ~ Q ~ofi (~,6 tl~ /oA:.6 ~ Bo • = b~;rebe! ` .a~o • 30 7frakit to z/LL L. ; 6 77 /ao y i T' a»• y y Ma~oric z ~arnrrro AU GALL nis ?9 O~Y T `s b Rio 9711 Bo PP ~cys ~P 9e, l 7 176/sia'~nyef' /?Q dc. B~ ,bo o t b .tlCV% Q `fKaPsreeSPaln da r'A '/o 1 /se2Roa.(-ford haP P s me P/EpcE COUNTY •$'tCioix County,r✓s. PHONE .(715)698-2471 LaPean Implement ~ UNN-_ SONS TOOL INCOPPOPATED 460 THOMPSON RD. SO_ WOODVILLE, WISC. 54028 East Highway 12 - Menomonie, Wisconsin 54751 METAL STAMPINGS - TOOLS & DIES SUB-ASSEMBLIES PHONE: (715) 235-7909 ~ e Wisconsin Department of Health and Sooial Services Plb. #67 3/70 Division of Health SEPTIC TANK PERMIT APPLICATION TYPE or USE BLACK INK A. OWNER OF PROPERTY Name Address (Street, City, Zip Code) B. LOCATION OF-P OPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY Check One: CITY VILLAGE LEGAL DESCRIPTION TOWNSHIP C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER - 4 D. SEPTIC TANK CAPACITY hJ7 d Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALS: Prefab Concrete Poured in Place Steel Other NUMBER OF TANKS TO BE INSTAL s E. TYPE OF OCCUPANCY Check one: One or Two Family Residence Commercial Industrial other Specify Number of Persons to be Accommodated Number of Bedrooms . F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer -IK_ YES NO Dishwasher YES NO Automatic Potato Peeler _I, YESNO Other (Specify) G. MASTER PLUMBER MAKING IISTALLATION Name: Addreses s~dG.J:lX t~License Number: /'/..cam !!t Signature of Applicant: MP RSW Addresss H. (To be Completed by Issuing Agent) Date of Application Fee Paid f Permit Issued (date) Permit Number Agent (Name) Fors 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.OU for each septic tanx and ths.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 I. DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) See Corres. FEE RECEIVED VALID. No. PERMIT NO. es or No REVIEWED BY APPROVED DATE (Initials) Yes or No COMPLETE OTHER SIDE r SEPTIC TANK PERMIT NO. REPORT ON S 0 1 L PERCOLATION ?EST AND SOIL BORINGS TO DIVISION OF HIA16TH - PLUMBING SNCTAN P.O.Bos 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Cods PERCOLATION TEST Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inchas Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall let Wetted Overniaft in Minutes Last Period Last Period Period One, Inch Example 0 36" To Soil ION C 26" 25 Yes or No 30 1/1 1 2 1 2 60 fl '4 " 02 o 7?,l -7 ILL- ~5 RECORD DATA FROM MINIMUM OF 3 ?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 Pro posed Abso tiara stem Boring Total Depth Depth to Ground Water Depth to Bodrook Number Inches Observed Estimated Observed Estimated Character of Soil with Thiolmess in Inches Example B - 0 72" 72„ Black To Soil 12N C 18Z Sand 18p Gravel 2411, .§A-44 ML4 Z 4/ 7k L RECORD DATA FROM MINIMUM OF 3 BORE HOLES P6 OF OCCUPANCY* RESIDENCES Number of Bedrooms OTHERs (Specify) Number of Persons POOD WASTE GRINDERS Yes No - Dishwashers Yes No Automatic Clothes Washers Yes No EFFLUENT DISPOSAL SYSTEM: NEW x EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Fsst Trench Width Depth Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pits Inside Diameter Liquid Depth'_ I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super- vision in accord with the procedures and method specifiod 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 may knowledge and belief. NAME TITLE Type or Print REGISTRATION NO. or MASTER PLUMBER LICENSE NO. ADDRESS DATE SIGNATURE REPORT OF INSPT .GTIGN---INDIWAL SEWAGE-DISPOSAL .,YSTLM PRMPRY TRE.MlENT consists o£ Septic Tanks Other (Describe) SEPTIC TANK: Distance from: Well %Pft., Lot Line ft. Building !'S ft. High watermark ft► 12% or greater slope -eft. Wetland ft. Cistern ft. No. compartments Liquid canacit~/®D D gal. EFFLUENT DISPOSAL SYST'rM consists of Tile field. / Seepage pit (s). Seepage Pit or Tle Field: Distance from: Well/ -7 ft. Building&ft. ' Lot Line ft. Cistern ft. High Watermark of water course ft. Slope 12 or greater ft. Wetland ft. Total length of tile lines/&ft. Number of lines a . Length of each line 2 ft. Distance between lines /Oft. Width of trench.776in. Total effective absorption area of trench bottom 0 ae-. ft. Depth of filter material below tile in. Depth of filter material over tile in. Cover over filter material Depth of tile below finished grade in. Slope,of trench bottom in. per 100 ft. Depth of bedrock ft. Depth to ground water ft.- Number of Pits. Outside diameter /"ft. Depth below let~ft. Lining material Gravel around pit: 2' Yes. No. Total absorption area so. ft. Square feet of seepage trench bottom area required Square feet of seepage t area required Inspected by: Title: 2 /1~" Approved Date / ,19, • Rejected , Date ,19 County, Town of Owner Sanitary Permit No. Property Address Septic Tank Permit No. Subdivision .v . yet , Ge r L /sue c. y air z - 0,4,s II P 1 b. # 60 i 3/70 PROJECT DETAIL DATA SHEET . ' NAME OF BUSINESS LOCATION` ,r r f street or highway city or township county LEGAL DESCRIPTION OWNER Mailing address ZIP ARCHITECT OR ENGINEER Address ZIP PLUMBER Address ZIP x. 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed: Existing building New building Addition If addition to existing building attach detailed memo for each. ( ) Drive in restaurant Car spaces - ( ) Restaurant Seating capacity (10 sq. ft./person) O Dining hall Per meal served Toilet waste Yes No ( ) Motel ( ) Hotel ( ) Cottages Number of units: 2 persons/unit 4 persons/unit TOTAL NUMBER OF UNITS ( ) Churches Number of persons Kitchen Yes No ( ) Bar or cocktail lounge Seating capacity (10 sq. ft./person) ( ) Nursing or rest home Number of beds ( ) Mobile home park Number of units - dependent (camper trailer) - nondependent (mobile home) O Retail store Number of employees Number of customers T10 sq. ft./person) ( ) Service station Number of cars served (daily) ( ) School Number of classrooms Meals served Yes No _ Showers provided Yes No ( ) Factory or office building Number of persons (total all shifts ( ) Apartments Number of bedrooms ( ) Other Specify 2. Indicate whether or not the following facilities are connected: Food waste grinder Yes No Dishwasher Yes No Automatic clothes washer Yes No Automatic potato peeler Yes Other (Specify) No 3. Fill in the appropriate information for the following as indicated: Septic tank capacity planned Percolation test results - ATTACH PERCOLATION TEST AND SOIL BORINGS REPORT SHEET COMPLETE OTHER SIDE Seepage trench bottom area planned width linear feet depth Seepage bed area planned width linear feet depth Seepage pit planned r' outside diameter depth below inlet depth 4. See approved plan for specifications and details. Signature of person completing form: STATE DIVISION OF HEALTH, PLUMBING SECTION P. 0. Box 309, Madison, Wisconsin 53701 Approved: Address.-- Date: ZIP.. THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIREMENTS AND DOES NOT EXEMPT THE Date: INSTALLATION FROM CITY, VILLAGE, TOWNSHIP OR COUNTY REGULATIONS OR PERMIT REQUIRE- MENTS AND SHALL BE VOID IF REVISED WITHOUT THE WRITTEN APPROVAL OF THE DIVISION OF HEALTH. DEPARTMENTAL USE ONLY