Loading...
HomeMy WebLinkAbout024-1036-95-100 p o O 6q 00 0. 0 ~ I I e o CD h N I I ti € I ~ I •o o d m v c c (n 0 v ai o a) Z z° w C Mn LL C LL _ O p N _ p N Cl) Ew Q N N~ 3 Q N y 3 co I 3 Cl) I Z y z vi _ c c Z V CC) O W m L m C,4 0. M F- Z o I I E z rn Z N Z E '2 E CO E ~w y, p ~i c J c t p c r O 2 Z Z O o 2 Z Z O N _ Z E C > m M > N y~t/l > V {0 G CL C l w Y c CL co m ooa` m E ooa E Z) E :3 zLn> CO fnlrA W ~I~ NV~v~r~rmr u 3 n cn ° ° 3 3 a aaa z a0aa a 3 c N r C, C> y I r aa00 p m J U y rn rn } Q) a) Z 0 CO CK C) ^I 3 0 0 E °o o ml a O - m N rn 2 0 (n Q m p o Q iA m Q Z U) N N N w O ~ ~ N C O E ~ H C O CS CS 1V C >>Q ~ co m a) c a d °o p p c i i N N N E m y N (A y 0 M c C N O O C N C N «O. co 00 FN O~ N co 0 O N y Z N N O co 12 0 N Z • N O N . En Q) co O E E R v j{ cli O Z N h z O M a - O Z -H -7 rd Cn O - _ T r`Nw CL a*•c dad` dad' R - CC c Y c c a; c +1 A a~ i) V 2 O U) C O m U -71 " %uevoZ pue %uryvuld A)uvoJ W13 7S DEPARTIMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: M,, SE 4, Sec. 30, T28-R17 El CONVENTIONAL El ALTERATIVE (If assigned) Town of Pleasant V-11 Holding Tank ❑ In-Ground Pressure Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSIDE TI A E: _ Dale Iverson Rt. 1, Box 47, Roberts, tiaI o A/~ _2 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. , CST F. PT 7 . cam:, x ,2,p a' = d 3,6 a ad, __2 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: tdm. Schumaker 6382 St. Croix 128798 SEPTIC TANK/HOLDING TANK: J,. J4 MANUFACTURER: LIQUID CAPACITY: TANK INLET EL V.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER / PR VIDED: PROVIDED: ecast- 1 4 ~ IO0, SS 59YES ❑ NO ❑ YES NO BEDDING: Vgfll DIA.: V64T MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T FRESH 6, ALARM: FEET FROM LINE: AIR INLET: ❑ YES O S~ E] YES ❑ NO NEAREST DOSING CHAMBER: GJ • . - ! z r-~ - 3.C~0 MANUFACTURER: BEDDING: , LIQUID CAPACITY: PUMP MODEL: PUMP/ UFACT R WARNING L LOCKING VER PROVI PROV /O W ❑ YES O 7~ SAY. 5 S Q/_S ES ❑ NO 21-YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTR LS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING' VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: BUILDING? AIR INLET: PUMP ON AND OFF L`YYES ❑ NO NEAREST 1100 > /GO >140 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: , DIAMETER: MATERIAL AND MARK ,~l M-t~" q(nG . or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN C CAS ~j - f~dC~ 8 5_ the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: INSIDE DIA.: # PITS: DEPTH: EN HES: DI GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: H BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: , ,gip' Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and f;;ES ws t wn unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑I S ❑ NO B-YfS ❑ NO DEPTH OVERT BED DEPTH OVER /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: i EDGES: r+ w ❑ YES L~'NO ❑ YES ❑ NO ❑ YES ❑ NO j PRESSURIZED DISTRIBUTION SYSTEM /0-/7 WIDTH: LENGTH: NO LATERAL SPACING: GRAVEL DEPTH B LOW PIPE: FIL DEPTH ABOVE COVER: BED/TRENCH G, V7 / TRENC ES: ~z DIMENSIONS 0 (p MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV, EL~ / 0/ DIA.:~ ~r ELE60'z " PIPES' DIA~~ DISTRIBUTION 14OLE SIZE- HOLE SPACING: DRILLED CORRECTLY: - / COVER MATERIAL: VERTICAL LIFT CORR INFORMATION 71 , r PONDS TO APPROVED PLAN G .rJS ES ❑ NO DDIES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: / IL"fES El NO Cc7ES-❑ NO INEAREST-~ ~>160 -'-4. C0-e COQ -~obe IJ-6t, n ~1 e> rr , : lL/ /`'dl~ ~ c:✓ L' ~"'C✓' ,a~,r~. -C..' c. , ,2( 51-~i ~,~~f`' ~ :-t.Bc".,d GCi /1-11" Sketch System on ain in county file for audit. ~ Reverse Side. kSIGNAFRIE: TITL SBD-6710 (R. 06/88) ' 1LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY an s Ezc: STATE SANITA Y PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. Cn k if rev! si t p evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. 7BER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. D PROPERTY OWNER PROPERTY LOCATION 3g 42C '/a, S 3D T•2 N, R 17 E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Y 7 ee-T,S Aw f% C_ I CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER If, Aj i aa1 q- Ii. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned VILLAGE ❑ Public 0 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL TAX UM III. BUILDING USE: (If building type is public, check all that apply) 23 7 1 ❑ Apt/Condo a ! 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 12E] Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 13E] 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.E] Reconnection of 5.E] 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 0 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 3?6' 3-:2 lam' y Feet 01, '"Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank , ~lJesT Lift Pump Tank/Si hon Chamber 1,50 l W 7- VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) P/ PRSW No.: Business Phone Number: 4VII, cr' e~ 14 a G s a SSW Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT E ONLY Disapproved Sanitary Permit Fee (Includes Groundwater [We Issued Issuin Agent Signature (No Stamps) 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 A 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 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 bya licensed pumper whenever necessary, usually every 2 to 13 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety 8 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; 8) 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 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 estabiishmenfolf standards. SBD-6398 (R.11/88) DEPARTMENT O,F REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN.DUSTAY, ' DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHI UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE 1 SE 1/4 3 o /Tze N/R ~ E (or p~ s vR L_~--Y - 1 t~ COUNTY: WNER' BUYER'S NAME: MAILING ADDRESS: R OV~~ t N~~ ST ~ I\)tmsoly I-Q-t-sT3~-rs wl s oz3 USE DATES OBSERVATIONS MADE 1PERCOLATION TESTS: NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 8. N3 , Residence a - New ❑ Replace `2 _1L/_ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑ S ®U ®S ❑U ❑ S ®U ❑ S ZU ❑ S 2U 1Fl n m- tAkGtA C=w4mvow ~R If Percolation Tests are NOT required DESIGN RATE: N If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: v n + PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IPdtHE5 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGH-EST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i bhLGY~5fI-rs $nsilto,7'u►~S1 ; B- l 5.6' ioZ.Qy No>~E ►»OT~ 3-t 2.H ' whl.Te'FS w/UF,; t3 ~ s- s BA~vos B- Z S. °1 0) ~vo~~ 41 D7- Ca 3.5 o- 81Dtiz GY (3h ail T3; 1-3' 3n S N ;0.-), aK aLvse y g, sI • 2.6' LT-. dn w/0 ft By%`iaeus - S @A/VoT 0.9' 6,e 3A sj I Ts; o,I; DV, Sjl; @n S); B- 3 S•°1' ~[-1.S i~on~~ hlni e 3.0 3.,z,' Lr.1yv"PS w/bft G3 't~"-k,se s 1 'aNxd s 0.9 ` 017- 6Y QK SO n ; \.o' Can s i 1 ; 0.- Ian S) ; B- L) S. S C l p T-*~ 6*kj morn Z.8 Z- C) L. l3~ s w olz Qv~ COCAs I BANV s B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. -PERIOD 1 PERIOD 2 PERIOD PER INCH P_ \ Zo )110 3l7 Z-1 P- Z Zx_5 1.~p 3 O 1 ' S 116 3 Z P- 3 ?_c~ KN 3b 1 1/16 z8 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. vs a. L~ f ` G 9 Z- AtzLAxuo s 1• I SYSTEM ELEVATION l-t C2.P 8 Q in* Z - )a-L. v_, 01 J___ I ~ A 2" WooA E N _ Lo _ O _ T = 13 ~~,ItE 0 i E E Dopy ~yCfZ ' 3 1 s c.~ L-C J= l 0 0 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: ADDRESS: 2vv~(•E Y Ta0Y, -2- -Z_ 6 CERTIFICATION NUMBER: ONE NUMBER (optional): L- sw0tg k.) s v011 S_% R`15 - (4 ZS- (3) 651 CST SIGNATUREA DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - I _A w. , :*s- 7 t ` aT ` DNS F _ V1PLE I FORM 1 t, 63 5 T c rt.C. t, 3Ct C(t3d, t`7._. a, f3t" t'Oolrl r ;'t„e£3l ~)~"CJf~C1r 3. Jai t 4, vs 5, Cc, lq JLY IF ALL 01-H- . L )lot elan, is d, A Sal 12. IL`1<' ~s. Ai-i. FH THE LOCAL ~.aJ PP . . ABI' i FOR ERTIF, I ESTERS tes and 1 10 ; L :.Y $b, f$ TO THE OWNER: This sail test report is 3 in ! ry , may request verification of this sail s for l.he private sewage systern and a utkority ;n order to obtain a permit. The saim y C _r, ..t mE a JOY COnstrUction. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER 6 b V I FIRE NO. CITY/STATE zip N : A S r~ PROPERTY LOCATION: AJ' r 'fit/4 S /4, Section 3O , T 2 KN, R Z W, Town of St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED l~l DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address Page 1 of F_ I,i OU N D SY S TEM FOR A :S BEDROO!"I RESIDENCE ^A ^ED IN TIE NEbY OF THE S`//v OF SECTION 310 , T zeR, R 1-7 W, OF N-),) T \1 NLLEY, sT. ~~Z_o I x COUNTY, WlsCor,slN. i INDEX: PA GE 1 of 6 TITLE SHEET . PA GE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW-CROSS SECTION PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT PAGE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE • PREPARED FOR U )V U- IR sON i2 vUT~ 1 a354 Q-1 TZU STS, W1 syoZ3 i` ,`odta,ezte:~g~;yrM, PREPARED BY o ^Sr w . -yam A]l-r. ASOCIATE. , . 1 i 1. 2 - 1'. ARTHUR L. • : M r V6EGEREFI e ^'r LS h'I 5402 z 6LLSWORTH. s wts. SIGIA .r - RECEIVED Job 88-/ 6 S JUL 2 51988 OFFICE OF DIVISION COnFC A%ln '^^raTnN _ Z 6 S ca le 0 b90 iJCT'E' L1..1STTxLL WgLL F'IT UZ-AST S& FfZLP-4 HOU-b i9T'i huL ~\T L %SIR ST Z S 'i = 0 m Tr'[ tc - ilof ?c s 01t~..~_ 51"tti K O•Shr Wa•vS t SYSTEM LocOYTON pGE GNSlTE SEW N s r rcH ~ r --t- _1 C T11 to of y GL ~ ~ E~,~pI r r RY . LAB~►1'\ 01L01 h S ANT 0~ 0 A QEPAATM DI S F S ,oS 0 NpEN~E o~ y SEE CORREs ` pV :;14'.• ONSITE EV1A64,°c p EM s3 ,1,3:--.'`,'~'-` T gh ~ ~.5J\ Do DoT c-OYlPr1GT OR 2 k . S A A \ T)' ! s~ a Ln1 F P ? \ Sp. ~ \o\ \ r` a je jCy 5 \ A~ \ 01 y°! o P- woo1~L~ ° i , h t~ Efi'"2 S T a:-- a h-. R.C) _'~1i1' Y a #Je Sw C-WWkst OP RECEIVED TtE IJ~ /iy. $ t_ ~~Y J U l 2 5 1988 OFFICE OF 0IVISION NOTES Urlr•• A):^ " T,,r4T1nN 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install cast iron pipe 3' onto undisturbed soil both sides of each tank. 3. Install permanent markers at end of each lateral. (L/ required) 4. Install 4" observation pipe with approved cap. ( Z required) 5. Septic tank to be - \Doo gallon capacity as manufactured by `.v 1 ~S l-~ CL1'►`► C2 c Tom. P~ ~'D V c._T S 6 Ranh ;;ark:- Elevation r1''i= z.lvo.p'.'~+.~-~ xz v~~ov sTA1=E wl -ATE _ i Sirow',.l~.orsh Hoy, Gr S90 ;v \ Synthetic Covering~ Distribution Pipe ~F a'ium Sand ~n G - ' F = N 100 Topsoil ~---1 - D I E % , V o• Slone Plowed Bed Of ~ ~LFor c e tJ gin ~ 2 - 2 Layer From Pump I A reootE oo _ TIO L R T D 1.O ~ E 3 ~T. Cross Section of A Mound System Using F o • 8 ~-r. A Bed For The Absorption Area A -~T• EWAGE SYSTEM g Ft. H 1 S 4T. ©NSqs S G .o n B L{-7 Ft. Ft. 110N5 REIA J g F . UM Boa o LAS ENT OF D RY. A 11.0 S l: t o F DEPART D1 t ESA L 6`1 Ft. i ENCE t`' i8 F t. see- OR ES NO L Observation Pipe J I K O S 7 r w- 2 - Distribution - \'--B ed Of z L ' w Pipe Aggregate 1 Observation PiPRECEIVED Permanent Morkers OFFICE OF DIVISION A 5ed For 7hE hsorptior. Arec L r Ur,d Using r p r=_ O~ rertorolet PiDt Deloll „s j / L nC V ir•. i - r, bottom. i LAI' c Spocec c. . e FVC Force, From Fump J r P PVC "Y Menilo!G Floc r v r r"Tf L O5Wolf S~OUIC Dt rv[i• iC Tn~ COr Z~•ZSYT. Eno Cor. Distriout!or, riot LovOul F' pNS1TE SEWAGE SYSTEM ~iioKS 3 0 1 h. E - ~ pr ~~Y incr DDR D HDIl U R A 1lD ) w in~~!, ---1 DEpkalmENS DF vs AF Later?,: 01 S oENCE Force hSain Z Inches SEE CpRRE pF= ?t~L~S~PIF~ RECEIVED 1rvvER~ ~,_EV~ ;~orl cr v~-r~u~s 1_ 0.9 JUL 2 51988 OFFICE OF'OIVIS'(1 Conn, SC) CC~?r~_IJt~G ; 67 t4, L-_ NS rT ~xM C~7i5Z OF r--?AMl Fb Lb IA31T,9 D C~°. ?iU! ` TN 3E N`x1- TO ( - ? 110. "W4 ~c S of p_ tiMP CHAMFER CRO55 SECTIM AM SPECIFICATIr) . 40 49 VCUT CAP y' C.I. VENT PIPE APPROVED LOCKIMG WEATHER,FKOOf MANHOLE COVERwITH JU►JCTI0IJ BCiX VJ RR1J 11J 6 l.°•B ~ = FROP'1 DOOR. II~MiII OR FRESH vJ1 I P, i)~TAKI t1O.5~ I 1 lI ~ \ I6MIA1. K.. PROVIDE I n r n I F UG IONIGHT SEAL GE P .~.f,•, ~SO I I ~ I APPROVED JOINTS S I c PIPE A / APPROVED JOIIJT w ON I I I w1c.Z. PIPE LJ I II ALARM LXTENDIUC, 3' C X T E ti D I W L 3 1J ~~►~~p I ' I ONTO SOLID SOIL OUTO bOLID SOIL p ` I RV , ~94R ~p1 I ow P C •~pF ~ ESPF ~ OFF _ EN tJ~ ~~NCC-ter-- L L E FT. PUKP o ' RES CONCRETE BLOCK 3 R APPRWOD ISCR EXIT PERMITTED O►JLy IF TAUK MAUUFACTURCR HAS SUCH APPROVI►L g~ppl SPEGIFIIf AT10US DCSE 3 •-7 PLR DAy *~►~KS MA►JUFACTURCR:W~ESt~R CDNCtZ.ETt AJUMDER OF DOSES: TA GALLOWS DOSE VOLUME -1 S O IJK ,IZC : 3O. 3 I~^TRa ~~JST~=?'i5 IAiCLUD1AJG DAtKfLOW: GALLONS AL/~hM MR►.;:IFA_TUFZC.R: S•~' ~L~` CL IJ !-1,ECR: lol Mt"1 CAPACITIES Ac IIJCHESOR 3'JU d GALLOWS 5 n IUCHES OR YC" GALLDW5 .-.:T=H; TSPC: - A,QUFA C.TUR►R: //ZIIJCHES OR 130.3 CALLOUS N~MP 'Z D•~7 MODEL 1JUtM16LR: ` s S L/ D INCHES OR.- GALLOWS 5WITCH TYPE: NOTE: PUMP AMD ALARM ARE TO DE y 1. 1 INSTALLED OW SEPARATE CIRCUITS MIWIMUt#% DISCHARGE RATE -GPM VLKTICAL DIFFEKCIJCE DETWEEIJ PUMP OFF AtJD.D15TRIBUTIOW PIPC.. 6*92 FEET RECEIVED + MIiJIMUM NETWORK SUPPLY PRESSUP E//. . . . . . . . • 2.50 FLET JUL 2 5 1988 + 52 FEET OF FORCE MAIM X 85 F/ioor>.FKICTIOU FACTOR.. 1'LI1 FEET OFFICE OF DIVISION 10-0Z. COnFe '04T-n4 TOTAL DtlUkMIC HLAD = FEET CiMEL.ISiO►JF Of TAWK: LEQ&TH - ;WIDTH .;LIQUID DEPTH J y ; P Y~ f~ AJ U F A CTV ~t `'l2 = ZOOS GAL / J Ai C H #1* ' -rl p p 1 G C Am I M r' P" F" T p'\ G~ 01. b O i. t Ez A Li I i v i i~ C: i - NNN N ON-A►OmON-~ C3~ O O CTI )491 a N O O ~ 07 m C7 U' -00 m 'U N ~ ~ n ° ° D (n . ~r C7 N R1 cn o C Q O r C13 r o -1 f~1 O N i (n~ z CA) 1 -U CO o m r CF) N O Z C .o ail Z3 Cil O N O O c n R CEl ED J I.2 H~ll Fl E OF TnN O O 0~ N -P O O -N W Ut ~1 CD TOTAL HEAD IN METERS S 88- 029 42 I " APPLICATION FOR SANITARY PERMIT 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 /V '57 Location of property A 112 1/4 SE ;Ll/4, Section 3L~ , T_?~N-R W Township Mailing address .6, 417 ~C 41 1' 66~'R Address of site Subdivision name Lot number Previous owner of property Total size of parcel Date parcel was created Z Are all corners and lot lines identifiable? Le"' Yes No Is this property being developed for resale (spec house)? Yes No Volume 9--/ 0 and Page Number S 0~i' 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, and 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. ---------------------------------------------------------7--------------------- 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 owne*ts) of the property described in this information form, by virtue of a war `.he Office of the County Register of Deeds as Document Ncsyu,E~ id that I (We) presently own the proposed site for the se : I (we) have obtained an easement, to run with the ( cty, for the construction of said system, and the same in the Office of the County R gister of Deeds, as Docume A4k-" Signature of Owner If Applicable) X Date of Signature Date of Signature M lk, c sip;' i ,~t r q a ~fl• Id's;" .;fi - r }r Mr~d '41^a. .1 - . 1 ~ it , lip, 1 • t f 9~ s 44 r ~ -i r Y r b it < r DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONSr, PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 r BUREAU OF PLUMBING MADISON, WI 53707 Neia,SEi4,S30'T28N-R17w ❑CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number Town -o6 Pteazartt VaUey ❑ Holding Tank ❑ In-Ground Pressure )QQ Mound 'I5='02942 NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE Date Iveuon Route 1, Box 47, RobeJrt6, W1 54023 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County Sanitary Permit Number: am Schu,maketc G382 S. Ctoix 112732 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL ILOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO BEDDING: VENT DIA.: VENT MATL.: 1HIGHWATER NUMBER OF ROAD: PROPERTY WELL: BUILDING IVENT TO FRESH ALARM. FEET FROM LINE: AIR INLET: DYES ONO DYES ONO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO DYES ONO GALLONS PER CYCLE: [LIMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING. VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) DYES NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nc, n, UTAM ETER 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: BED/TRENCH WIDTH LENGTH NO OF DISTR. PIPE SPACING COVER J INSIDE DIA #PITS LIQUID TRENCHES. MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER IF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES- ABOVE COVER: ELEV. INLET. ELEV. END: PIPES. FEET FROM LINE: AIR INLET: _ 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- DYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED: MULCHED CENTER. EDGES. DYES ONO OYES DNO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: `W BED/TRENCH DTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER. TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.. PIPES. DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: F-1 YES El NO ❑ YES 1:1 NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) Zoning Admi.nZ6 tAu;On ( State of Wisconsin \ Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL SAFETY & BUILDINGS DIVISION Office of Division Codes and Application 201 Fast Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 WEGERER, WEBER AND ASSOCIATES Owner: DALE IVERSON P.O. BOX 74 ROUTE 1, BOX 47 RIVER FALLS, WI 54022 ROBERTS, WI 54023 RE: Plan Nutter: S88-02942 Date Approved: July 25, 1988. Gallons Per Day: 450 Date Received: July 25, 1988 Project Name: IVERSON, DALE - RESIDENCE Location: NE,SE,30,28,17W Towrr of PLEASANT VALLEY County ST CRO'IX Fees Received (Priority Review): 160.00 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 plaris. 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 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. 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 I:LFIR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: NEW MOUND Inquiries concerning this approval: may be made by cal:l:ing (608) 266.-2889. Since e 1 , ETER PAG - L. Section of Private Sewage Division of Safety and Buildings PPP013/0009n/47 cc DALE I:VERSON ___Private Sewage Consultant Caunty UW-•-SSWMP --Plumbing Consultant Owner Plumber Environmental Health SBD-6423 (R.10/87) • Pa ge 1 of F_ MOUND SYSTEM FOR A 3 BEDROOM RESIDENCE LOCATED IN THE n► f~Y OF THE S E//v OF' SEC TI ON 30 , T zBN , R 11 W, TOWN OF Q'LE`s'\Sf~ 1T \1f\Ll.E~l, S7. C,ROIX COUNTY, WISCONSIN. INDEX PAGE 1 of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW-CROSS SECTION PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT PAGE S of G PUMPING CHAMBER PAGE 6 of 6 PUMP PERFOSMANCE CURVE PREPARED FOR ),\j ~R 54 N_. \2uUTE 1 t3oX 4-1 ~U[3~TS, Lv! 5~loZ3 i`',,od~sareuto~p r\SCONS PREPARED BY ie 4 AND ASS00I T / . ~.i vmp JET • - ARTHUR L. WEGERER t .T. / ' T C 7 n r. r~T / • 4915 P F i~Jw.'SIi`< 0~2 _ riI V u t~LL • ELLSWORTH, ~ WIS. •S • ~~~°~ssRe ~eoo ON 0 411 ~_zc--z8 S 88- 029 42 RECEIVED Job # 88-/65 JUL 2 5 1988 OFFiCE OF DIVISION COncc ANIn *^^Irer~pN t' LU'1 r i..~. h Scale ~oIAJSTtRLL w;: , - RT L-k6t5T 50' Fi,L 4 )"70ux, r~ ~ti~ ~T L~sRST Z S' F-Izc\ m N 'NI U K O$ MI Wa+vS S1TE SEW AGE SYSTEM Lo cA--'n 0 Ot skt:rcN W r; EL~Tlptki y t (p`oe 14 C-1. D R`l • A ILDI s ~ QEPAfITM~N~ Of f S Di S Q ,o~~ NDENCE y SEE GORRES ~ ,o~ L C B 3 '~T B~ fF~ ~ys~ ~o ►-~oT X1"1 P~c.T oR S AS P to 2~' ip Z D~ ti 1 S Tv C Tk 1. ~4 e L P3 woo~L-b o~L-iv aZ o. Rte i1aT Y LI &J e sw c o~ of RECEIVED T*e k-)E //v- S G <<y JUL 2 5 1988 Q Q g -9: 2- OFFICE OF DIVISION S V V ` 0 NOTES co!?Fr, Pin r-ttr,'TTN 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install cast iron pipe 3' onto undisturbed soil both sides of each tank. 3. Install, permanent markers at end of each lateral. required) 4. Install 4" observation pipe with approved cap. ( Z required) 5. Septic tank to be - \boo gallon capacity as manufactured by Lv 1 V--- S &'1Z co 'j c-~z G:TL PR 3Uy C_T S b. tench Mark- Elevation j l u ~ Sl~i~lr.'\~ wA i ~ HR~~►J~ ~x~~►.~L~ ?F~E~~T t~VJD~I~G f~T t~;~~}ll.l. S II~E _ G ' y<<~ ~p= S1rov~'~ ?J orsh Hay, Or Synthetic Covering . Distribution Pipe .I - Medium Sand -~G Topsoil ` F _J V 3 E °j, SIOQE LForce moin Plowed Bed Of 2.-2%z From Pump Layer Agoreoote D 1.O ~T- F 1 3 ~-T. Cross Section Of A Mound System Using F 0.8 RT A Bed For The Absorption Area G ``o ~T SEWAGE SYSTEM A 8 Ft. H 4T. ONStTE B 4-7 Ft J \Z Ft. OR p UM RELATIONS 8 Ft. t~y D RY A S SA K ~ o Ft. DEPAR'NENQ QF F IlD 6`] Ft. a i NpENGE W za Ft. SEE OORRES L Observation Pipe-m~ i lb - J ~ ~ K FAIN- I I, C I _ - W Distribution Bed Of 2 - 2 2 Pipe Aogregote Observation PAIECEIVED Permonent Markers rnnrt', n. Pv--?1f'%TnN S88-02942 tJ,vund Using A Bed For The Absorption Area F-L Pbrforoled PiPf Deloil E nr Vilr i J { Lf'7001[C / ' PcRr1A~E►~' HAR✓.ES2 `PVC r pt nr DL-, LDC Died [1n E0110T, .!fl>.~+r Arr F o,olly Spored tl~ b ~ I S Q PVC Force MOM _ From Fump O ~ - PVC ,C I MonilolG Flat fi,5 i ~ ~ pr i Loll Moir Snould bt~ I,r N,,,7 iD End Cor p Z1-ZS-FT• End cop DisiriDuitOr, Fiat Loyoul ONSITE S~pGE SYS~ y $ yin. S X 30 tn. t,pYtONS i3 0 1 h . E y l.AE6R Ho I e Diameter 1~y Inch D iLDt 1 ~lylnche DEPAfl~E~O~~ t F SAF ~ L a ser a i Manifold Z Inches CDa < pEt E "Force Main Z Inches SEE G+ RECEIVED ~NVear Ev>k-noN of~ 1Do•9;. JUL 2 1988 OFFICE OF DIVISION S88-02942 IZ1 CSfJ ~ OF t-~ f1N) F=U D I I TSB SC] LAST HU! 1U 3E N1=>CT TO `t~7CD CAP._ . ' PUMP CHAMBER CROSS SECTION AND 5PECIFICATIOAIS C) F 6 VCIJT CAP 4" C.I. VENT PIPC WEATHER PROOr APPROVED LOCKING JUIJCTION 8OX MANHOLE COVER WITH , 25' FROM DOOR, wAR1JIIJ6 L+'.SLL IZ~M11l. I wiNDDw OR FRESH AIR IUTAKE F1. I o3 5 D* •I~ Mlw. ID'Mlu, CONDUIT - - WMIN. ~MPROVIDE INLET PG~SyS'SM1'RTIGHT SEAL Ct~se* I I (I APPROVED JOINTS APPROVED JOIAIT A ONS I III W/C.I. PIPE W/C.Z. PIPE CXTCIJDIwG 3' ALARM EXTEUDIU& 3' V ONTO 30LID SOIL 0►JTO $0LID SOIL 8 ~P I I RY ~$0~ ~,p1 i I Ow E P I + D Nj pF U F SP %f I ; L L C V. a O FT OFF D EE COR~~S i $ COUCKETE 5LOCK i 1 3•' APPRWOD RISER EXIT PERMITTED OWLtJ IF TAWK MAAIUFACTURCR HAS SUCH APPROVAL. gEDpImfi 5PEGIFICATI0MS S88-02942 OO6CK MAWUFACTURER:wLlSG~8 r~1JC1ZE NUMBER OF DOSES: 3•~ PER DAU TAWK LPIZE : S O GALLONS DOSE VOLUME S.S • EL LCTRO 5YS 7 5 INCLUDING bACKFLOw: 1 30 3 GALLONs ' ALARM MAWUFAGTURCR: MODEL ULIMBEK: CAPACITIES: A= 1S IMCHCSOR 10SY GALLOka SWITCH TtiPC: 1"1 ~~RGv1ZL( D = mr-WEVOR Yo' I G~LLOAIS i PUMP MAULIFACTURCR: r' E y E=" S 'O' C: 6 IULKES OR 130- 3 GALLOws .I MODEL WUM6CR: S S L/ D w INCHES OR llko_7 GALLONS *-I I L'~2C.i12-( MOTE: PUMP AND ALARM ARE TO DE j SWITCH TYPE: MIAlIMUM DISCHARGE RATE 4Z,,Z GPM INSTALLED Ow SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEIJ PUMP OFF AUD. DIST RIBUTIOU PIPE.. (''9D FEET RECEIVED t MINIMUM NETWORK :SUPPLY PRESSURE/. . . . . . . • 2.50 FLET JUL 2 5 1988 + FEET OF FORCE MAIM Y, !_'!8S FYoFLFRICTI0U FACTOR.. '-'41 FEET OFFICE OF DIVISION to-%Z CDPCC AfJ'1 +rnr+np TOTAL DtIUAMIL HEAD = FEET 'ulP%mETE9_ ESOY 'ME- I)S r~ Y RIS / IQTERAIAL. DIMLWSIOwJ OF TAWK: LEKICTH _ ;WIDTH r;LIQUID DEPTH ~1:.G-19k 7~S P ~Tl A 1J U F rA CT\J R t:FN2 = Z O. O S G A L- / Aj C- H a• A > I r- s TOTAL s a a a rr P~ p ~ 6 ~ 1= ~ ~ N N • N N I~.1-~.fOcoON-A►OWON4 O ~ O Cn N O O O n Cn m O D D oN ° ~ (J) -~N fi to cn O C O p ° r ~ r ° op 0 w Cl) CTI O N ~ 1 V ~ N Cn ~ C Cn o rn -a art o C N QI O O Cn R GEi ED ~ L 2 19 N OF?I of ai It Tin% O N O O N W -p Cn m -•J M CD TOTAL HEAD IN METERS S8'8-02942 SANITARY PERMIT APPLICATION COUNTY DILHR In accord with ILHR 83.05, Wis. Adm. Code 7-' 2" 01 X E,n„~„~ STATE SANITARYPERMIT# -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. 2 ? -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ® No PROPERTY OWNER PROPERTY LOCATION ~c 11E S Q T,2 r, N, R E (or a 02 P PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME RT l Af e{ q7 h'ebcyfis 023 CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK Q 3 El VILLAGE : 1 4 II. TYPE OF BUILDING OR USE SERVED: f Number of Bedrooms if 1 or 2 Family. OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. WNew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System 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. ❑ Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding C. E] 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. ❑ Seepage 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): l 41~ Ky 7rG 6 G6~Y Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 0400 1 Lift Pump Tank/Si hon Chamber Gf 1 1 19 ❑ 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 Signature: (No Stamps) M /MPRSW No.: Business Phone Number: GJ~rll.'am Sir ~f~r Gr/ ` X63 ~`2 38~ S Plumber's Address (Street, City, State, Zip Code): / Name of Designer: / r aL° Q G✓C Vlll. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # 490 e ,,,,y~ S'~ c CST's ADDRESS (Str City, State, Zip Code) Phone Number: IX. COUNTYIDEPARTM T USE ONLY gent Signature (No Stamps) ❑ Disapproved S nitary Permit Fee Groundwater ate I M; Approved ❑ Owner Given Initial rcharge Fee 2 o,v) L6A_e__3 iok s Adverse Determination X. COMMENTS/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 A 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;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; 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 Ground atar included the creation of surcharges (fees) for a number of regulated practices which Wisco in+5 a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure 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 credited 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) ST. CROIX COUNTY d WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE • 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 July 22, 1988 Division of Safety and Buildings Bureau of Plumbing P. O. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Dale Iverson property located in the NE 1/4 of the SE 1/4 of Section 30, T28N-R17W, Town of Pleasant Valley, revealed suitable soils at a depth of 3.0 feet, below which high groundwater was noted. This site should be suitable for a mound system. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, Thomas C. Nelson Zoning Administrator rc ST. CROIX COUNTY t!WISCONSIN ZONING OFFICE r r x n r n■ r■ N11146 ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road „_._.,y► Hudson, WI 54016-7710 (715) 386-4680 July 21, 1994 Ms. Jean Utecht 1168 Rolling Hills Trail Hudson, Wisconsin 54016 RE: Septic System Dear Ms. Utecht: Per your recent request, enclosed is a copy of the Inspection Report for On-Site Sewage Systems, Report on Soil Borings and Percolation Tests and Plot Plan for your septic system. If there is anything else that you need, please do not hesitate in contacting our office. Very sincerely, Marilyn K. Zais Administrative Secretary mz Enclosures ST. CROIX COUNTY WISCONSIN 17 ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 I Nov. 8, 1990 Dale Iverson Rt.1, Box 47 Roberts, WI 54023 Dear Mr. Iverson: The mound septic system installed by Bill Schumaker for the Dale Iverson property located in the NE 1/4 of the SE 1/4 of Sec. 30, T28N-R17W, Town of Pleasant valley has been inspected by the St. Croix Co. Zoning Department. At the time of the inspection this system was found to be in compliance with local and state regulations. Should you have any questions regarding this matter, feel free to contact me at this office. Sincer ly, mess K. Thompson Assistant Zoning Administrator cj