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HomeMy WebLinkAbout030-2044-95-000 -0 C) ~ o i ~ o I °o p 69 d ti a O ov ov 0 o (U C) o o rnp~3~ N y 7 C C M 7 p c N CM N N 3 C C O O N QJ aci N C C fy p E p c C d _ C LD y a p N 0 X C C O CO N t C y y CL 5 'x N w S 0 'c Z +p`J 0 0 0 c c~ o Z. 01) d 1L o y HY yw d 3 0)mmo 3 Q cm c a o) a C M c ,It W E p N U) % w 0 Z ~ ~ d d N H Z ! a m Cl) ~ _o I 0 z d c c N ~ M N C. .C d m N c j Q L = o ~i c c O Z Z z N 0 N C7 C N H d N O N o G O IL E CL m hw o V~v) N ~~a N* h-- 5 3 000 00 a z 4i (L IL CL 0) 0aCD U) -1 0) CD } M ~ a I II r r _ ~ N a ~ r o o "Op ~ I -6 co 3 w c E o p 3 d IA Q `noH a c cia°oI O O N E O y m N N d O 7 CD co a) `C N C+Oj N N N O Z C N a • y O N (n (7 0 Z c I- m Cn r E l • a m ;v ~ a 3 w o U) Q 4 A i f Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ZOO - ~ ~ /LtST.rcY/t TOWNSHIP ~~t,eV/ SEC. T N RA- W ADDRESS /34// iS !N 5r_ ST. CROIX COUNTY, WISCONSIN ,14L L TCUcJ 4'-'l SUBDIVISION A,)A LOT LOT SIZE NA PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ~ST I / ~ • 13e.~~.yM~4~t'K CC/rit f` Z-1.4 V. X00 ~w /~fs.,OCNcC I I Awl-, I I GU f5 0 ~ VI I I I `kSiST/.~/G /OOO GAL • i i 3s Szot•c -7-4AI/< ~Tr/ q/c~ / N i f ^1AA///J4C .t~NT~PANCC /~ILsJ 1 ONT/SA/S~eCTio a~ ag I w~rN i~a~P~vt/c/J P244r, Se.oPd ,'nRi ✓_6-WA- Y i INDICATE NORTH ARROW I /l~v Sc~~ BENCHMARK: Describe the vertical reference point used Al-W. r!'a,ruF~' of TP Sr Elevation of vertical reference point: /00' Proposed slope at site: /f? SEPTIC TANK: Manufacturer: VA Liquid Capacity: /000 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: AIA Tank Outlet Elevation: 'e'60' if,,) 9O~ o Number of feet from nearest Road: Front,O Side,O Rear, 2f feet ..From nearest property line Front 10 Side 10Rear, ~ feet Number of feet from: well 300 f , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: " Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM L~✓ A gam. mod. Bed: Trench: 6 Width: S Length: S~ Number of Lines: / "AIMArea Built: S Fill depth to top of pipe: T®f, 46 3 [Number of feet from nearest property line: Front, O Side, &Rear,0 Pt. Number of feet from well: SOO 4 v Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: /3©0Co lc Number of pits: / AZ tt> Diameter: /O~ -JI Liquid depth: Sog4 Bottom of seepage pit elevation: Area Built: T'S- ;r- 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: - Dated: s O Plumber on job: License Number : lWt 5 3 9$' 3/84:mj ~q~oooc' DEPARTM OF INDUSTRY, INSPECTION REPORT FOR SA ETY & BUILDING DIVISION LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION P.O. BOX 7969 MADISON, WI 53707 State Plan I.D. Number: iiTW4, SB 4 i Sec. 26, T30-R20 ❑ CONVENTIONAL El ALTERATIVE (If assigned) Town of St. Joseplo Holding Tank ❑ In-Ground Pressure ❑ Mound F IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: dward Gillstrom 1341 15th St., Houlton, WI 54082 ca- I Q-QC~ t 130 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: appa Bros. Inc. 3395 St. Croix 135428 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: +17 1/ 1 / ai,)- ❑ YES ❑ NO ❑ YES 0 BEDDING: VENT DIA.: VENT ATL.: HIGH WATER NUMBER OF ROAD: PRO WELL: BUILDING: VENT FRESH ALARM: FEET FROM LINE' f AIR INLET: ! ❑ YES ❑ NO 1 ❑ YES ❑ NO NEAREST---* DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTUR ARVIN OVIDED:G pROVIDED:OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: MBE OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET PUMP ON AND OFF ❑ YES ❑ NO NEAREST HST _♦DIAMETER: MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: DIA.: # PITS: LIQUID WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: iiLE BED/TRENCH TRENCES: / DEPTH: DIMENSIONS 15 1 G.- c~/ / GRAVEL DEPTH FILL DEPTH DIST. . PIPE DISTR. PIPE MATERIAL: PETY WELL: BUILDING: VEBELOW PFD : ABOVE COVER: ELENLET: E . N : ~f~ E: AIRI:(7 02 / MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. IL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: E:1 YES ❑ NO [__1 YES ❑ NO [__1 YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL] NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO ERTY WELL: BUILDING: O PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF T FEET FROM EP COMMENTS❑ YES ❑ NO ❑ YES ED NO NEAREST /,31 Re in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE.:-- 7 SBD-6710 (R. 06/88) r~ ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 2/ 8% X 11 inches in size. Check if revision o revwus application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ,g~5'4 w 5 '/4%4,S 6 T3o,N,R .2.0 E(or)OW PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # A/,* CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 7'~N G✓ • ~ O 89 i - NEAREST ROAD II. TYPE OF BUILDING: (Check One) El State Owned VILLAGE : ❑ S-7 30S-._-,0,V ~ S ❑ Public 01 or 2 Fam. Dwelling-## of bedrooms ~ PARCEL AX NUMBER() ©3O_ 9 _C"j Ill. BUILDING USE: (If building type is public, check all that apply) ~o Y 0 1 ❑ Apt/Condo Y 1 -1 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2.~ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑Seepage Trench 22 El In-Ground 42 El 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) -ew-- 50~0E6TION tr. SOO :5o.A- Feet Feet CAPACITY VII. TANK Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed G.J d £ Septic Tank or Holdin Tank GAO /COO It Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: sC. Plumber's Address (Street, City, State, Zip Code): /1/ _ryo,14 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given InitiaSurcharge Fee) /,316 Adverse Determination [ X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 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. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) I APPLICATION FOR SANITARY PERMIT STC-100 I 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 'Il Location of property X1/4 x/4, Section , T 30 N-R 20 W Township Mailing address y v 8 2 Address of site ZZ l~ T'/v r~'rn~cT Subdivision name Lot number Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? es 0 Is this property being developed for resale (spec house)? Yes No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND 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 Nap 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. % ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. Sign ture of Owner oe-.,) Signature of Co-Owner (If Applicable) 7 /?o Date of S gnature Date of Signature STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER C~nJQd - F ROUTE/BOX NUMBER 11 q":~ / 5- FIRE NO. ~ CITY/STATE 1 ,.JCt, C,VAA, ZIP Sys B PROPERTY LOCATION: X1/4 1€ 1/4, Section, T 30N, R0 W, Town of ST , St. Croix County, Subdivision L/Q . , 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 / /1c~` `r°"r' DATE q d 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 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, cc DIVISION LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON W 53707 (ILHR 83.09(1) & Chapter 145) LOCATION- SECTION: :WNSHI OT NO. BLK. NO.: SUBDIVISION NAM tjJ/s~ V/ 31 MON/11/9 0 5-r Josr~N COUNTY: MAILING ADDRESS: JrC06ix <-iTcVIEEPIcKS&vj 199 MC KINL0 iaQSol., W, '5401 USE DATES OBSERVATIONS MADE NO. BEDR : COMMERCIAL DESCRIPTION: & New Residence C4 41JNew ❑Replace 4A/,g9Z3o, 90 )A^) 3/ RATING: S- Site suitable for system U- Site unsuitable for system 4,b-z- A>"gxV ONVEN I AL: M UND: IN-GROUND-PRESSURE: N-FILL OLDING A K: RECOMMENDED SYSTEM:(option 1) ros ❑U S ❑U 0S ❑U gS ❑U ❑ S CoNVE fo AX ~E~ If Percolation Tests are NOT required DESIGN RATE: If an any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: CLdSS 1 Floodplain, indicate Floodplain elevation: WA PROFILE DESCRIPTIONS BORING TOTAL OBS jjQ R ATE -INCH S ARA T 0 SOIL WITH THICKNESS. COLOR, TEXTURE. AND DEPTH NUMBER DEPTH40. ELEVATION V D F EST. HI IF OBSERVED SEE ABBRV. ON BACK.) GREST TO BED B' I I,l~ 80.4 6 «TS .z" RNStL 29"f2tl>4~N5, 3l 2d,$a•v►'h5 oN 52" 8aNCS 4k -Vc" B. 7- 9,(-7 '74.69 NONE > 9.6-7 8Lf_~rs /&*Re-4S, L 9"Y&aN s, 2- ' ae',l r-/ 4t 33 eNF/1'ls L7*'LT&N GS 4"A I! %Wre- 14" B+tvSt L- S Z" RoBew S t 401, lea RN MS B- 3 IZ.`l~ fir; ,S4 NO N IC > /7.9 Z A.,tr 9 t'-4 cis _V c B- 71. 0 /3'8LcTs l3'' BQ.,tS L ?0 kP&RAN MS .tt 4,JM CS ONK > /133 ?Z"SRy CS-fG-A, B- 4'&L-15 /3~/8eNS,L /9'Qo A~ )L SS Qo tZh U -27 oNl~ 7 9,~i 2 t-_T_ B- Da PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME LEVEL-INCHES DROP IN WATER RAT MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD I R PER INCH P- 1 5.16 c) W if 9 ~ /V P. z C,90 N N 7G.So O >Z >2 >Z < Z P- 3 .)O 7.10 U > 2 >2 >Z lZ P- P_ F_LEq!4 IOW AT M AC- 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 pl plan. Show the surface elevation at all borings and the direction and percent of land slope. 211 SYSTEM ELEVATION. 69.70 ~Pod j rtc ►'u►--KP.. l _Qs - to i Gicvv 1k I _ wr- I F %ism 64 1, the undersigned, hereby certify that the soil tests reported on this form were ma3e 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: 14AevEY JoH~tsa►~ ~oN~ISa>,, Supvole'a 1h1ic- 34+4u-A+ky 3/ /990 ADDRESS- _ CERTIFICATIgN NUMBER: PHONE NUMBER (optional): 4o7 S cad s ,V(joSo,,v r ~v1 b 34T5 ~U- 4og o CST SI TURE: 0 DISTRIBUTION: Oieg,nal and one copy to Local Authority. Property Owner and Soil Tester. L n„ uo eon -9 In n.nw. f 1 (,Jest I ~ ' PR~PE~ery I L-.~NE ~E,v~r/MAfI~ : is Nom. C~,,e..,~t oy I f ToP SrEP i,~/ /~e/J CRiF-~/o~J PLB 67 I /9q - ioo: PLOT & CROSS SECTION PLANS f SLGPE ZAPPA BROS. EXCAVATING INC PLUMBING UNIT f JfiJTS. f PROJECT f 1 ' S s~ Rap ,3oxES f C/P/Rf5ID4NC4f GOL✓/#.P i cST~Po I '540,.,e I 1 1 /3S// e7aU is 7- 1 JENn /a I 1 I ~ ~ l C7Ix C71GN \n f 1 Y1 ~ so I ' ~ ~fn S / sT/.c/6 Co'.fc 'SLPfi c /ANK ~ I NE.w M.tv slot i En, T/PA c~ i NEw C.<. C[f.WOUT c~.TN r1AF7fvu~/~ PI(KG ( 1l f.N~s ~ / / / 1 A/~w ~iFucfuT ~iNE p'.~°wsv StPric To ` -J ~ '~k-S l S TI.v 6 ~if S- wB4rE ;yf/v Exb-/sTi-ve ~~t~W6tL. ~SL oPt - _ 1JF..~ /3ov Co,4. ~R/ .ivs-rr~lt/O w.TN ~5, Y" G1 L ~ Sc.,~EC qv ° l3~ts~ 4f 15 E NO SCALE S'CartTN 6'Qca/L~'"TY t'. i.JE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 12' ABOVE FINAL GRADE 4' CAST IRON PENT PIPE '4,0V MAXIMUM OF 42" ABOVE PIPE TO FINAL GRADE SIGNED: MARSH HAY OR SYNTHETIC COVERING LICENSE: ~~S 33 95' MINIMUM 2' AGGREGATE DATE:/ g /yc~ OVER PIPE DISTRIBUTION PIPE i -T TEE SOIL TESTING B . ELEVATION BED 6" AGGREGATE • BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW TESTIS • COUPLING TERMINATING ~ _ v-, FT, AT BOTTOM OFSYSTEM 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) Be LOCATION OF PROPERTY WiARE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY Check Ones _ CITY VILLAGE LEGAL DESCRIPTION d ryp 1 q TOWN HIP prj C G i Oc l~f Icy .L~3 i~ C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO / Cl PERMIT NUMBER D. SEPTIC TANK CAPACITY 717) Gallons NEW INSTALLATION -14- REPLACEMENT ADDITION MATERIALSs Prefab.Concrettee Po ed in Place Steel Other NUMBER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY Check Ones 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 YES NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) Go MASTER PLUMBER MAKING TALLATFON Names Llk Lk/ Address$ Jam! It ~.44 (k "ioense Numbers Signature of Applicants MP RSW S,4 k -Ac't H• (To be Completed by Issuing Agent) Date of Application Fee Paid rms n t Number fY , Permit Issued (da/tee) Pe Agent (Name) ' -zL Fort Town, Village, City, Coanty, etc. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the tee paid. Agents will forward application, the fee of $1.00 for each septlo tank and the third copy of the permit (canary) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY 1. DATE RECEIVED 1 ACCEPTED BY RETURNED (Initials) (Date) See Cc rbs.) FEE RECEIVED VALID. No. S) Gj p PERMIT NO, es or No REVIEWED BY APPROVED DATE (Initials) Yes or No) COMPLETE OTHER SIDE . ~j SEPTIC TANK PERMIT NO. REPORT ON SOIL PZRC0LATI09 TEST AND SOIL BORINGS TO DIVISION OF HEALTH - PECKING SECT16H P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code pSRC0LATI0N TEST Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inohes Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fell lst Wetted Overni in Minutes Last Period Last Period Period One, Inch Example P - 0 36" To Soil 10" Cla 2611 25 Yes or No 30 2A 1 2 112 60 A A/O RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S 0 I L B O R I N G-5 - Minimum 36" Below Pro osed Abso Lion System Boring Total Depth Depth to Ground Water Depth to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches Example B - 0 72" 72" Black To Soil 12" CLAX 18111 Sand len uravel 2411 O 2 ? y ` RECORD DATA FROM MINIMUM OF 3 BOPS HOLES PE OF OCCUPANCYt RESIDENCES Number of Bedrooms OTHER: (Specify) Number of Persons -31 D WASTE GRINDERS Yes Noly" Dishwashers Yes No Automatic Clothes Washert Yes v No EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT ` jS- Tile Size No.Lin.Feet . r e- Trench Width Depth Number of Lines y~ Seepage Beds Length Width . Depth Tile Size No. Lines Seepage Pits Inside Diameter Liquid Depth Is the undersigned, hereby certify that the percolation tests reported oa this form were made by me or under my super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin-Administrative Code, and that the data recorded and F"" tion of test holes are correct to the best of my knowledge and belief. NAME , i ; " ~ TITLE jY,i11/f Ii' Type or Print REGISTRATION NO. or MASTER PLUMBER LICENSE ADDRESS DATE ~4 SIGNATURE yc -•a AT , L