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HomeMy WebLinkAbout020-1035-70-050 ap u°4 AD: o v N c c a a O O O 2 m.E N 0 a p` o as O N L N 0 .O. (D c N C 01 N T V C 3 O € N a E aD O °� � �E� a 3 '06px 2 aEiaNiy (D N O•j 0 3 V E N O a) 7 N 0.0N CL O OQ N TOO>^a)Y O O a — L'O C ` O2 7 Z -0.0- Z Z a3 O liU _ o ° O O U. O CD w Zas -a Eo•€ m N 3 CL o € E 3 Et �,,2D v U v�m2a) cm ac a Q3a 0-Ow C) ° Z N Z N Q, w E E °o = o° Z d y a a, m m w ;', am am o z a c (D z o o cm~ c a) c E E N N N a N j m d m (D CL CL vi N N N • In d L d L O O Q z m Z z m Z 0) NN 'o Q o y - m o y - m 3 xs any c �, C w y d m ocCL ooa` c EL 0 3 3 3 0 3 3 3 • R = a a a =a a a a CO o U) J UI, z z O N N = m ° _ _ cc 'a MO On ... O O a m c a m c O _d Q Z (A Z (/7 C m y N a s ° o w oO 3 0 v w c 0 U W M O C N M C m a) m C m Cc Co m m N a • O r 2 O r- N Z N m Z Q 000 M Z w = _ U ` d a. • c� o m .� m a y a t A U s O U) U O i) U a \ 0 2 C) o m j & \ $ (D . 0 , o \ \ }cO c ° ° .a- \ $« Sl) of \ § 'okjam) A %f§ ID ƒ )§f7E t (D CL E� m2E 36=� - � (n c � k\ /\\ § LL k �5 - [7 #k \/ I X00 0 \ E < � �� 2 cc \ o cl \ ) \ j ( E g � w § j } c k z \ ; z m § (D k § \ » \ ` e CY / � Q } $ z � .• a I 0 k / .0 1 . a) 48) — ® ( Ln J C E/ E .� \ § § § ~ $ : ƒ a a a \ 0 \ k § \ o ° z \ k § ® 2 \ \ \ \ $ G C. « \ E ; - ° 2 a \ a f k < > ƒ CD � ■ \ ) 2 & � � § < ® \ ] 0 E _ k ° § k \ ) 7 r S \ \ \ \ ) a \ E @ t ) 2 7 \ \ / / 2 0 3 § § m . e z a g a § a k@ _ > e Q a s � E c o ' G 2 f A g o z $ § 4 \ � 2 « $ 2 \ k a C C , , § ■ o 0 a. \ / k v T. INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 r` „ To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city,village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report,the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis.Adm.Code will be applicable. 10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system, depth of the system,type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan,drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances,distances between beds if appropriate,tank locations,effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit.Private sewage systems must be properly maintained.Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years.If you have questions concerning your system,contact your local code administrator or the Bureau of Plumbing,DILHR,State of Wisconsin. Wisconsin APPLICATION FOR SANITARY PERMIT DILHR (PCB 67) OUNTY � TTnenr OF UNIFORM SANITARY PERMIT# i==NFMbM InDUS InOUSTFV,LRBOF 6NUTFin RElFiT10n5 � ��/� a —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS G A, T Xk A 4Z .Z Z1a,0ja,,, PR ERTY LOCATION t 1/ fe1/4, S �, , T� , N, R E (or) W TOWN O 4i f ,� LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER L TYPE OF BUILDING OR USE SERVED ❑ 1 or 2 Family Number of Bedrooms: Public (Specify): T c/ /V G THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair jX Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound X In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity VDU r Lift Pump/Siphon Chamber O .t Manufacturer: PERCOLATION RATE ABSORPTION AREA I ABSORPTION AREA WATER SUPPLY: (Minuted per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): �� ® Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: /MPRSW No.: 1"("Pip one Number: D62A/ 2Aa a I I j r_-�?_Bqo 6_ Plumber's ddress: P IV P Name of Designer: w d COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved Ad ❑ Owner Given Initial J I/" Approved Adverse Determination Reaso for Di ppr l: Alternate course(s)of Action Available: DILHR-SBO-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 1 BUREAU OF PLUMBING MADISON,WI 53707 ❑CONVENTIONAL CXYALTERNATIVE State Plan I.D.Number IIf assrgnerf) ❑Holding Tank UIn-Ground Pressure ❑Mound 8603654 NAME OF PERMIT HOLDER: I ADDRESS OF PERMIT HOLDER. INSPECTION DATE. Duro Bag Manufacturing Rt. 1, Cty Trk"A", Hudson, WI 54016 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REV PT ELE V Etz of the SE14 of Section 17, T29N—R19W, Town of Hudson Namr•nl Plwnbec MP/MPRSW No.: County Sanrtury Perms Number: Gary Zappa 3300 St. Croix 83815 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET E LEV. WARNING LABEL LOCKING COVEH PROVIDED PROVIDED _ ❑YES ❑NO DYES ❑NO BEDDING VENT DIA. VENT MATL. NIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING VENT TO FRESH ALARM FEET FROM LINE IAIR INLET EYES ONO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP.SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED PROVIDED DYES ❑NO I DYES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPE H I y WFLI H TO flit 511 (DIFFERENCE BETWEEN FEET FROM LINE INIET PUMP ON AND OFF) OYES ❑NO NEAREST—�1111 SOIL ABSORPTION SYSTEM.Check thesoil moistureat thedepth of plowing LENGTH 1101 A111 I11+ IIIATIIIIAI ANDNIAHKIN(V 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 jNf_)_0_F DISTR PIPE SPACING COVER INSI OI Dln SPITS I IOOIH BED/TRENCH /") TRENCHES M if L! PIT DIPI1f DIMENSIONS GHAVELOEPTH FILL DEPTH Ut,III PIPE UISTR PIPE DISTR.PIPE MATERIAL NO DIS NUMBER OF PHOPEHTY WELL BUILDING VENT TOf HFSFI RF LOW PIPES ABOVE COVER !I!V INI E I ELEV END PIPES FEET FROM 1L AIH INLE T NEAREST 10 MOUND SYSTEM: _ Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TP XTUHE PIHMANI NI MARKI HS I IIISI 11VAIIIIN WI l IS _ ❑YES ❑NO _ _❑YES LINO DEPTH OVFH THE NCH HED DEPTH OVF H THENCH BEU I)EVTH OF TOPSOIL SODUfO SFFOfH IM..CHIU CFNI EH EDGES ]YES ❑NO ❑YES NO ❑YES NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LE N(iTH NO.OF LATERAL SPACING GHAVEL DFPTH HE LOW PIPi I Il L UFPIH AHOV( COVI H BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PIMP MANIFOLD DISTR& PIPE MANY OLD MATERIAL NO DISIH Ii1SIIf PIPE DIti IItIHI)IIr1N I'IV'1 hiAIIRIAI &MARKING ELEV. ELEV. UTA ELEV. PIPES DIA. EV IBUTI AND • RIBUTION ATION HOLE SIZE HOLE SPACING URILLLD COHHECil Y COVFN MAi EHIAL VE It fICAI 111 T CORRESPONDS TO APPROVi U PLANS ❑YES ONO ❑YES NO OMME PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING FEET FROM LINE ❑YES NO ❑YES NO ___ NEAREST— Retain in county file for audit. [SIGNATURE TITLE } PUMP CHAMBER Manufacturer: hI.ZF��2 Liquid Capacity: GioL Pump Model: ,?-�j /QJ Pump/Siphon Manufacturer: - Pump Size / Elevation of inlet: 9Q f3 Bottom of tank elevation: Pump off switch elevation: �� y Gallons per cycle: l 7 Alarm Manufacturer: 2,L- ✓ Alarm Switch Type: Number of feet from nearest property line: FroGnt, O Side, ®Rear, Ft.� Number of feet from well: .� Number of feet from building: �d (Include distances on plot plan). SOIL ABSORPTION Syaiv�)' Bed: P,1k=&LJrench: o/ Width: y� Length: b Number of Lines:- Area Built: �bl Fill depth to top of pipe: '? z ( y,?-,/ Number of feet from nearest property line: Front,/ O Side, 0 Rear,O Ft .� Number of feet from well: 0 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• Dated: ^b Plumber on job: License Number: 3/84:mj i Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP _ 1�unsv.✓ SEC. TN-R�W � V ADDRESS 97f-- ly/,/Ddo" , ST. CROIX COUNTY, WISCONSIN SUBDIVISION /'/A • LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM OdE R ISO -16 h.O rerN Pno oogRT Y FEn�GE �U.20 �l'JG {✓EST /RJPF_2T% Lam.,.� /�p�vL<Fia cruns n�G /3LI�G L XSSTS�G Lr1.ty_ - 99. 4 /ll+— /07 Pa O o OV,�EIt Yoo� To EicST NOTE' �-ELL SS IOO -rAsT Fieor„ l7ars / thZC?I..G S1�%r�crarv�c f LOFt LVNO=HG OncK / • /0� A/tgA y WzrN .zrvStrLA-r.LVN 9XnTZNG GAaA6 F_ . ASPNrJL r Dves o/ rxzsTZ.�[° INDICATE NORTH ARROW To SOU7)J AnF00 A10 .j chZ LLTNE � BENCHMARK: Describe the vertical reference point used ZY1S-na,,, 49, o� ,� rr�d .rte LiwE Elevation of vertical reference point: '100. UO Proposed slope at site: ZlqD SEPTIC TANK: Manufacturer: 7 � Liquid Capacity: oC�OV Number of rings used: �_ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,(D Rear, 0 -zo O feet From nearestproperty line Front,OSide,O Rear,(9 3004 feet Number of feet from: well ).�"b building: /D (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE \ �N INC- VII tA ' I C> II � All II . I d n 2 14 v co G I ry i 11 Z • . 0 fij I I 0 0 � n � � d14 face" t NI 86 03654 PROJECT ITS D 3X SHEET OWNER: R a G- AV - IUD ADDRESS: jf f /j�Lvl! J� //VO•SD� GfJ/S'. .S�G� SITE LOCATION: fps r %` PROJECT DESCRIPTION: ��nIQ CU�if'E`v7� ^ 1'71S 7- e$Wr TiN Cr- sys 7Z-,&l . 4 NeW ,N feoovp &,rS ooeJ rf/sye'•r %S IF'�ppJ�p 0 bz� Si2-ED AXT410 oN 170 �04QM 74 ;A ( �Mp ay s -�- `Fto�R porl1A3S , -Ifsf6�Aj IOAoi PAVE S ! AI-iv�t,� S i � say 1 - t ST-ro As ct-4ss T 1 will PX- g /1't�.'��. SST►M>'1'rED PAiLr luASZE WATtR fr<Dw = 3,50aj;LQ ,4GE Z. j',V6Avav,0 1,PFSfdos e4,eOXs e7' &E,0 f�fIGE Awl) CA,t'`r/3�.2 SE�Tic ?�•v1C �L� vim w s ,av y� ��i/J�f,GiE� �i�osS S,E�Tio Av , PLUMBER: S IT.R� EVALUATER or DESIGNER 3300 NOMESITE SEPTIC PLUMBING CO. Ill 30 NEIL RD.,HUDSON,M&5401f �l�� U MIS.MASTER PLUMBER l C.NO.3307 M.P.RS. A a/e ,y .� Qi�j �� .• �7 d��j MINN.INSTALLER&DESIGNER IIC.NO.OM3 DATE: • SIGNATURE c" f d, ef f�'e'V1' XSv�°�PEp / y ! 10jyaS"41 01flYeS :r 4-// Xn 7(.4,,_,_ S s S� N �rtcfi 0V0 J`/4D "O'k-F '7� �f-// /r y S,4 of xf� r Ah p P OVA I ' 1 0C rAos i u&-- ,p-4-v ANa i%.t,<,..- � -N ��o�,vo ��ESs�,e� cross sE�Tom • a z„ g90 Fr 86 - 03 .654 1 fIPP�'oc�r> syu��%c fr 3.S I owe Pip 40 . Ll i V ZlIz oAse Rv f rlo,.,) A �tk Seri- TE5 T w;f� %• �oles �/�Ur�Ti�y a/� ,C3f.1� �G�tiD /E!/�1 �R Olp-u ,ti iAS r ��� _ t�5/ L�// Fr, OrsreiBvTio,u / FT- 6F P I ?E . r � PIPE iNuEQs' (-S7[ZL 0 P,. ��� 1 IV G-ROUND ��Essv�PE Xr pc'Q ra P4 0/1 a f�EP,y�y�lfcr/' t __ i vfNTS / LOS' Df' scALDu/e- vo ?k s/oPeo °' ya°AGY�ur B,4c& To E.vTif%jG /�1/9N/{d/O Pump CGtAM sue_ RECEIVED JUL 17 1986 Pt , p A 0 CO ------ ui 4' f Q FkFCF IVED r L va- _ !`\, a. WZ 2 J AZ 41 R a- e i 4 <C I �' Z� � ° h ►ter., . N r N a O Cr XJ CO . 2 1 Q .� � it, •,V 2 L� a V `` Q oQ <a--- cc kL I G \il h Ju a OL CY 1---L, S j kN k% RECEIVED 11 JUL 17 1986 PLUMBING BUREAU o - � � O Vol) 1/o/o y't � f olp ee- j 0 Al- 0 PUMP C HAMBER CROSS SECTION ARJO SP CIFICATI BS 86 . VEIJT CAP 4°C.2. VENT PIPE -T WE�R ROOF t APPROVED LOCKING MANHOLE COVER 25' FROM DOOR, M 10 X NS WINDOW OR FRESH 12O AIR IIUTAKE OL• ( 'p JAL - �"iv,�rroN • Z3 t rr PROVIDE I ----- AIRTIGHT SEAL sf/a VAN APPROVED JOINT;' A I I I APPROVED JOINTS W/C.I. PIPE �!►/�i}L �� '\ `-' I (I W/C.I. PIPE EXTENOINC. 3` Std%E.S I I(I ALARM EXTENDING 3' ONTO SOLID SOIL B 51 !N I ( ONTO SOLID SOIL i ON ELEV.Y6' FT. 0 �lE✓Af/0� , /NSiDE of PUMP -- OFF r IU«T �. g5 y" I^Nk .,. X 9O CONCRETE BLOCK �IEll�flON RISER EXIT PEKmiirED ONLY IF TANK MANUFACTUKLIt HAS SUCH APPROVAL SEPTIC f 8PECIFI'CATI0MS DOSE. �oruG.�.��t--- TANKS MANUFACTURCR. IJUMBER OF DOSES: PER DAS TANK SIZE: Z"@ �' GALL0WS DOSE VOLUME ALARM MANUFACT ER• X.-,664 /9/A,pM IKICLUOING GACKFLOW: � F.ALLDNS 1 ?.ro d MODEL MUMBER: '�'y�" CAPACITIES: A.�IA CHES OR GALLONS SWITCH TSPC: A9F+PPVAY /C/D,f T Z /7 g= INCHES OR �1� GALLONS PUMP MAWUFACTURER: ouG�"` -z.uc C= 2 INCHES OR/¢77 GALLONS . 3887 /M R1 WS/oB - BfSepIEs • . �� MODEL MUMBER. D. INCHES OR GALLONS SWITCH TYPE: 2 PI y RRCIr *M�RcuRy F'Io�4TS MOTE: PUAP AND ALARM ARE TO BE MIKi1MUM DISCHARGE RATE GP INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEU PUMP OFF AND DISTRIBUTION PIPE.. / FEET �qNk' + MIIUIMUM NETWORK SUPPLY PRESSURE . . 2.5 FEET Eifl.� ti ♦ FEET OF FORCE MAIN X L F/o0 nFRICTIOW FACTOR. FEET TOTAL DtIUAMIC. HEAD FEET \�05 da S s7 .. 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I 11 >.11 i _ 1 4 , I 1 1 K'I 1 , I 1 , 1 1 1 I .I I KI • 1 K1 1 I 11 I .1 D1 L H R safety and Buildings Division PLAN APPROVAL Bureau of Plumbing P.O Box 7969 XGeneral Plumbing Plans Madison,Wt 53707 Private Sewage Plans Telephone:(608)266-3815 ter.-►�Qs�_Te S� moo. ups o,.< PbName Project Location -Street No. or Legal Description CA,20 C4 Co . S mac. 17 ?-q 4 1cl v./ County %. ❑ City ❑ Village Town of: 14 H Dso _ / C T C O J 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 construction site.The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3C 3d 3e 3f 3g This approval will expire two years from the date approved below.If co on has not commenced before the expiration date,new plan approval must be obtained. FOR PRIVATE SEWAGE PLANS: (1) (2) (3a) (3b) (4a) Nri Vk) This approval will expire two years from the date approved below, a sanitary permit is obtained,it will expire the day the initial sanitary permit expires. The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only.All other system reviews must be submitted to the Bureau of Buildings and Structures. Comments: By: James Sargent Bureau Director If Questions Plans Approved By. Date rove . Contact cc: P ' ate S wage Consultant ❑ Plumbing Consultant ❑ Environmental Heald County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-S MP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099(R.01/85) ❑ Owner 11 Other STATE OF WISCONSIN-DEPART`4ENT OF INDUSTRY, LABOR & HUMAN RELATIONS SAFETY b BUILDINGS DIVISION - BUREAU OF PLUMBING P.O. BOX 7Q69 - MADISON, vi 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Towns hip/M y2 s� i1 4 �9 yv�-rov S �iC�or�C 44-4- 1/4 Section/7 N R Street Address: Subdivision: County: //./ C/y /Pp , f¢ PAI T e 6.9 -.vvvSLF1*/ r9C-1.t s Landowners Name: Mailing Address: Abtv vA7WWiV c{ - �� • �vvtv,�.� lv� s S/4/0 I (We) , the undersigned, make application for an alternative system on the above- described premises. If approval is granted, I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged- with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspecting the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. \ Signature of Applicant Date STATE OF WISCONS0 Subscribed and sworn to before me this COUNTY OF S' �i4 a r x date: ;2 7 Notary Public, Stag of >d 3con31n SBD-6413(R.08/85) My Commission Expires: V JUL 21 '86 15: 74 LUDL-W P. 2 : / r u>oaaoD m w "of Oma r YM Pl wo .trti Maa J.') i I6ie )adenita Made hle dPl of_ � rc h A.D, 1912_ be„=R RO P PEA � ___*UA a � Rr ted Md-dull•t �in!>xd and es tra d the!hate of GIs under and by :{ d the ins Pat, sad %; Pte'•—.•...,._ of the ercmw pan• it f►��( / • bb I Wimaeetlt, Ts.t the said Pert1 of the Ant p�aeL for and ,'nooidet•d a the rue ±� '1 10 It Paid bP the mid Piet SC.._.«_of the. _ d part.the .*J.whereof 1. -�'.'aaruw yo r i eabtew!edtted, by Storm, deaasd, bar aieed, field, nrmlyd, Mood. sad herebP mod, 4 sad . quibcldmed, wd by I tArw Pta°a dw fly $=I. wsab Will mm, reiftll�and�. eLuO unto the uid Peff—V ...at the sww tad es.i.._ imp s. toreros the lello.in dma&ad Graay o! 9h1b d Wla000a;a,toewtf s teal —I&L "anew In the f � , fir A parcel of land located in the NEB of the SEh and the SEk of the 9Eh of Section 17, T29N, R19W, Town of Hudson, St. Croix County, , Wisconsin, being further described as follower: Dettinninq wh the >awtar, to aorr►¢L VC stravlon 171 thenca South along 1 the section line 1793.63 _*net; thence west 533.00 feat; thence ?i Northwestern Railroad right-of way;lthenca S e 18c00 wnd said Northerly line 446.67 £eat to Norr-henrly 14-o, -a I� r=yt•te-z -#%-; Lnence southwesterly along the arc of- -a-669.9-2�£oot radius curve which is concave Southerly and Whose long chord bears i' S 780 46, 18" w 180.87 foot) thence N 19.59124" w 17.00 feet, thence Southwesterly alonq the are f a An .t:1 f.%^,. .,.aj.._ f ..•e..a�. auuL eriy and whose Q t;ong chord bears S 67 018,20" W 88.72 feet to the South lints of the Szk of the sZh f thence S 89022100!! W along said . Forty line 141.70 feet to the Southwest corner of said forty; thence N 00°02110" W along the west line of the SEh of the SEh and the NEIL of the SEMI of said Section 7626.68 feet to the Northwest corner of the NEC of the SZk of said Section) thence N 89e3040" E along the North sine of <as !• said Forty'1333.00 feet to the point of beginning. The above described ' to existing Town RoadaRight-of-Ways contains 68.498 noses of land subject TAX EXE:M. 77.25(7) •. ;, i l Or x MM"At[T,ooxTixas Oseasa p.=K ON IIII7tate7 MD111 To lb"atld to Hold the um•,toietho with all am sl lar the a nP► PPunaaaanw and tuifllesee lhrtrttoro heloapud or is and wise ty (I dwmmm •ppensintap and ell the estate, tisht. title, intcnet and dalm WhanoeTer of the aald Pane of the first " I(� loo or eltpoauary of, to the oaly PmPer we, beandt sad P•n, dehet in law or agttitf, �amsm Polt9v6l hohoof of rite aald prtt:_y»._of the aelarttd part.._.]t..L I Iu Wlooeee Whereof th ' ,I l e said j!k??ufacttiri„�{� Imam of the tits'pare, has rsn•ed there Preettan to be iPnad b IN Ansideru.and .unto , __ } --_. _. ._.__ ,____•_� d by X�Y.3.I.-QT w....__... . I� •_..�•.�, o.41r....� .�,13y ..._... ---•-,is S•o'etu", * I ��•-•.— dq of__,_ Y Y!][ �r,A.M. V• •find IN C019mte mmJ to be hereunto a>fi:e4 this aaxaa AND eta use fix _ Marc h 3 Patae+xas or IXJR4 P _ .AC-=N TAL'rU?, W, CCld_PA.Ny_ r, I Ilr ate Tilt amito s'rA'rs or _» �• ` ZE1.i(„.�,.,�.�`c.�!�� l ---•--•-- • caW, " March ' P4saaal Y'erne before 0%thin.___, I s t 83 day of— .« -----,A.D., 19_x., • d � abof a _, rreaideat,sad. S V V 1 a�•_—� ! named CoMoetloa, b lae known to be the Ptn*U who exemmd the lon haidaltt and Serreu:y of yid CarfotaetM and UJUIOv Whin i;Amtateat. sod to me imo,ra ro he ryah nN CarParati ledied that thq �eettted the laneo oe ittlttUafeat u +laW oSJeen at the deed Of oa hf In a4ehorEry. a ' WAS O"AITeO ■r Y/`w Ol'i Hugh P Odin, Attorney xorARTI _ Glavin, Gi:bert, cm-n, 41dge 6 Porter"'' `%art Alhlic, ._ _ Kenton � KY ' -mss•--za'`-�'== : .z:-m-���c-s:. taepife 1f. 1 fit) d W'7lxfnae Stttvlh mWu --- is,_..._�......... _-�_ � oM e•alw ta•[Heys!• trl.+«+. f,rrvuw ae ens". W iarWnrna n a rlsWy roll Y•.r f1uNr�r,flee o."sl-r,a,o ra•rwa •ores'/ �h,ea• a•l,ee atca "'w'sa fe" .M•U w• M nteem 11 Df iuiia'Y�rd aissir It,Sf.4 1%.tM►•,roe•+w e,te.wa• A t9T CLAIM DAtaD..O one tonne r e :ea,►y euew,.t 7 Cfreeratiq ITA?fe m MtsaUyRx wtaefMta tw�l ltua Oereeear { . .. -....�.� ti......�.._.. ......•.....�r........ .,.....w..eon„.rte....,+,a:r...y.rt.�.u..,.. .•..�....w..arw.:�..�,.�.��ww.. --.w».• � ✓ j STATE OF WISCONSIN County of Sn' On this thr aaY of IL_ before me, the undersigned officer,personally epptare )Mown to me (or satisfactorily proven) to be the peraotk.— whose name nbaoelbtd bo t the within Instrument and acknowledged that—�bt._executsd the same for the purpose therein contained. In witness whereof I hereunto At my hand and official seal My commission axpireff Notary Publio STATE'OF WISCONSIN l • ' Countyot ( �• i, 111 i On thin the day et �' I7._,before me, the undersigned officer, parsooallr appeared e known bo me (or satisfactorily proven) to be the peraoo— whose nam / .biCribed to i the within instrument and acknowledged that—114--aocuted the tame for the purposes therein Contained. In witness wharoot I hereunto set my hand and official sell, my Commlasiom expsas Notary PubIio � CORPORATE ACKNOWLEDGMENT Kentucky state of�OCfil6ii” county of Ken ton } gs• 't On this z6th day AD. lD --� before me, the undersigned penonsliy appeared S, .David Shor and -RS htzt M, Moore to me personally known, who being by me duly sworn ; did say that they are reepeclivelyh$ a g Board .?Wdf�nDCan� Tr Of --5h421$ZZSi_Eate r r i e s n Tr s , Corporation; that the seal affixed bo the foregoing instrument is the corporate seal of said Corporation; that said lnstrument was signed and sealed In behalf of said Corporation by authority of its hoard of Directors;and said—_ { . S. David §kQr and RQberrt M. IIOre severally acknowledged said instrument to be the free act and deed of raid Corporation, illy commission expirea_ Qr t- ?�$ _ rns�_ �D D•'✓ v Notary public C j �_ m-iam eo:,ST 98, tiz -inr now"It"mKrwu1­74.. ` CONVEYANCE- Or- LONnq Tn MINTY FOR 14IC14WAVr PURPOSICC i the IIld0011) _ w# Hudson -.- r-7,1.`::• .:�.�;i%:..•"..:i �t:i�'.;,. �.. ., '�'.u• l7i-sj't�t�3' as raCa{red"���Awr�t�h �efTf� tt�,. +k' '������ .na � • Y ra M cemm.ae•. r..ra.e'�a..♦ Lr •e.a.••t ,+{tfiil�.. v . v. as lJ iruW, w.,�„ ^.... ....• a+ tna u rneaa.•aa, snot ens all- owner (s),fora v.,ualilo consideration to-wit. - - - - - _ - - Dvtt•.• ( rnnn nn • r l•.v.,i '`t:..t:n...::+:•;p..w.. .Y_.i!• '!•-utt 1l:.�i.:�rJ- iii v i[:.-..vr•...n.n.•,. ,. . e�{ 29N♦ R19W. Tnwn of 14ttdenn, St.1 Croit County, Wisconsin, beins furthnt- da2ar4 tte.4 w. i 01 laws: vt.-cornor sacrvn 171 thenaa •OV37'13"w (bear lttya r crrretut.rtJ the East line of said SEA assumed N0016'11"W) 813.31' along the centerline of County runk Highway "a"; thence NOd22'41"E 50.00'; thence N89°37'19"W 76,77' to the mont.mented eaLeriy r ;Wirt.-w r'-way 11it" nt rho rntra90 inn ,veren%,,eetlrn 4a11read, aaiti point: owing the 04nt o* 6eo4 A4„Q; .cl nni IAl"W -11-W -t,l rtnv 10,oa• an an CHI 9eI ng t.- Iron ipe on the existing Northerly right-of-way line of said highway; thence Southwesterly}� n said line along the arc of a prgg�tp S reC r ae 69.6fZ' r diva rurva 'rnnrav Qn,tfh_ ncrnrt wncxa tong enord uaare SJN ]34+I�YW 36a. i� gprcriouaty I4vurJc%J eb 370'40'14"w 80,87' to an existing V-11rtnrpipL-, thence an said line (11 03-38"W 16.90' (Previously ereardod at N18060124"V117,001) to an cxlol,irty 1" trust NINci Wiertett 3outnwe3zerly on sal° ' ins along the arc of a previously recorded 686,62' radlls curve concave Southeasterly • hose long chord bears S67°06'12"W 88 99' (previously recorded as.S67°18'20"W $8,72') to ' n existing 1" iron pipe; thence S 89308'05" W (previously recorded as S890221W) 98.75' 0 the proposed yortherly ri?ht-°f-way line of County Tr,Jnk Highway "A"; thence North- asterly on said line 371.36 along the 'arc of a 868,51' radius curve concave S°uth- asterly whose long chord bears N78 0714311E 368.54' ; thence S89 0 37119"E 37,65' to the oint of beginning. ? Said parcel contains 0.237 acres (10306 sq. ft.) and is subject to easements and estrictions of record. Right of Way, etc. V. The grantor releases all claims to any trees within the said iende, and understands and Agroea that the Purposes of tills agreement include the :lght to Preserve and protect any vegetation existing on the said lands, and the right to plant thereon and protect an vegetation that the highway Authorities may deem desirable to prevent erosion of the soil or to beautify the highway, d A covantat is hereby made with the gsaiidooSt. Croix County that the said grantor holds the above described ,ild Promises$good o it e pa d clearl tromvall dens and tencumb encumbrances,whwstoever $01& and hereinai the t forth. • This conveyance shall be binding on the grantor, `h, heirs, executnrt tarlens and grantoes, and silo consideration h<roinbetore nalncd is acknow;edged to ba in full payment of all'c!aL•na of whatsoever nature by the grantor Arising through or by reason of the granting and conveying of the said lands. -..,� . Aa None being the ownsr__and bolster ^t•. eettafn- lien_sga:not slid promises, do hereby loin to wad consent to said conveyances of said Jien- • WITNRAA tho henna a a.•I ee t6• e.•wter -d th. fat....!_)vluura Art and consenting to tau C."Vey once, this °K l,' - e �day of— In Presents of a"" ••tT ,.- —r '-5-� / l (SEAL) _ t ` (SEAL) f ----�.. (SEAL) (SEAL) STATE; Or WISCONSIN 1t County of On thfa day of.�_.—_.lo. baton me the undersigned officer, personally ap?esrfd_--- `_ _ �,�.�•. known to me for sstlatactorily proven) to be the person-whose rame_— •re lubecribed to the within Instrumrat and eoknowlcdgod thst_hl- exeeutcd the fame for tIvt pvrpoaes therein coaufned. i In witness whereof t hereunto sot my hand and official seal. Hy e0mnlission expires -Yobry Public ---Project 6944-C6-2 E'd _._....K .. .--• _ � ... m_ icm sa:sT Gs. TZ -inf,-•-- 1....w.... ,JUL 21 '86 15:06 LUDLC-W- P.4- r 1 srAsr Or W1200—r_ra 1 County o! r U. On th14 We- Air pt_ -- - 2P_...,before me, the undersigned*Ulcer,pUM&Uy eppeered known to me (or pUdietortl9 tiroven) to be the eenoit_ whoee name Akubscribsd W , p (n r m � � N M o O (D � 7C A A (D 7 V " a3 ° � w w om CD O a A ` w o (p (O (D :: M:—0 ,< - _. 9 r m ?T CD tDo 91 A i d O .+ (p (Q W p w _% =r c c V oo � � c w_ � cn' j W 2i c l< cr 7 ,. _w wwv, j w CD g � o am < ((D 0 Q �(Q Q A C) (D 0 si p D c - ("D o Cc 0= Win — O e (a -% w = � (D O � O Na 7 ? C p�j 7 N C N �}m N N (D0) CDw (n Z \$ � '� 0 c Z CD am0 39vw, � Na D N C N 0 g A M N (D ? - A 7 iT ? � a a c A * w � C m (`4 j CO (D N (D .w. N n .. (D w m =& Qw = A lqc\l ao f CO) c c f In m � M (wAS m CL Q � acv; tp cr C 0 (c' `< �• (D (D b A u, m o CD 0 7 0 (0 0. C � � C (p S CL c w (D Spwi .:. A CN Q 5Da =' c (D = o i o o ° 3 liy CD 0 < 6 ••� � . a . _.w y D s.A I L.�,._H R.w�s Safety and Buildings Division PLAN APPROVAL Bureau of Plumbing P.O Box 7%9 X E] General Plumbing Plans Madison,WI 53707 Private Sewage Plans Telephone: (608)266-3815 6 8 milli jay f T . ®_� ___a �_ _ 0, �yc /a ONE= Pro ect Name Project Location - Street No. or Legal Description County ❑ City El Village f�Town of: (� 5 � ti0 The plumbing plans and specifications for this project have been reviewed for compliance wit 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 construction site.The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g This approval will expire two years from the date approved below.If construction has not commenced before the expiration date, new plan approval must be obtained. f t C` FOR PRIVATE SEWAGE PLANS: (1) (2) (3a) (3b) (4a) (4b) (6 "(7) This approval will expire two years from the date approved below or i a sanitary permit is obtained, it will expire the day th permit expires. P y e initial sanitary The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only.All other system reviews must be submitted to the Bureau of Buildings and Structures. Comments: By: James Sargent Bureau Director t If Questions Plans;Approved By' Date prove Contact y �' � -PriGate S wage Consultant ❑ Plumbing Consultant ❑ Environmental Healt County) ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099(R.01/85) 11 Owner 11 Other 1 + R INSTRUCTIONS FOR COMPLETING FORM 115 - SRC - 6395 To be a complete and accurate Soil test,your report must include: 1. Cornplete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedroorns or commercial use planned; 4. is this a new or replacement system; S. Corril3lete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TALK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE us(, the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate skeet may be used if desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; S. Complete all appr cpi late boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. tf we infori-nation )such as flood plain,elevation) does not apply, place N.A. in the appropriate box; 'i. Dgn the form and place your current address and your certification number; 12. M;A 4ecilbic C0t)i0i aild distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY VVITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols 'Iorw l� ve'r 10") BR — Bedrock cols - Cobble, {3- 10") SS — Sandstone gr — Gravel {carder 3" ) LS — Limiestone "s Sand HGW Nigh Grocnsdwatca cs - coarse Sand Peerc — Percolation Rate med s ._. 1"Jedium Sind w VIVrtai `,s Fin;= Sind Bldg -- Building Is Loamy Sand j — Greater Than sl — SalAy Loarn Less Than { -- Loam Bii Bro�vr� `sii Siff Loam RI -- Black si — Silt G Gray lci Clay Loam y — yellow sca - Sandy Clay Loam R Red sicl — Silty Clay Loarn mot — lllottles S€- ar�tty Clay wt wittr sic — Silty Clay fff -- few,fins,faint C Clay cc - r,c,I'll nfon,coarse Peat rrrm Many, nlediurn d — distinct r) — prominent HWL — High watcar level, Six general soil textures surface v,,ater for licfr.rid'waste€ isposal BM — Bench Mark VRP — Vertical Reference Point TO THE OWNER: r hips s011 test€-epOrl is the first steep ill sc;curing a sanitary perrr,it. The county or the Department may request tr s sc,iI v" in "he ficid prior to pl=rmi€ issuarsce. A complete set of plans for the private 300 a !*,1;sinii z pplice, laic must be srhrriittfd to the atypropriaiee local authority In order to ._ r.3ir? r ,;h t:trt ;ae sal . .ars ltt rrT"dtt PTttt�L t_be€ 772<,Sr�z Cl and pOsted t ioi to the start ;=f ally , � t t,��es�t"r�i 3e"JCI, DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY; - P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) RUMAN RELATIONS MADISON,WI 53707 (H63.090)&Chapter 145.045) LOCATION: SECTION:T e p W TOWNSHIP�TY: LOT NO.:BLK.NO.: SUBDIVIISION ,N/AME: 'If II4 �/4 /7 / 2f N/R�/E (or)R U�10 tf �i1/P (�� r7�i[�3� COUNTY: OWNER'S/BUYER'S NAME: MAI.LIIN Af6-- �/• �• fr J T �° USE DATES OBSERVATIONS MADE NO.BE COMMERCIAL DESCRIPTION: PROFI DES RIPTIONS: E ATIO TESTS: ❑ ce 6ic7-6,4 ❑New Replace I A� 2/_ RATING:S=Site suitable for system U=Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUNDPRESSURE: S STEM-IN-FILL HOLDINGTANK:RECOMMENDEDSYSTEM:loptional) ❑s au ❑ ®u ❑s au ❑s au as ❑u �srwl� P ercolation Tests are NOT required DESIGN RATE: iFloodplain,If any portion of the tested area is in the der s.H63.091511b),indicate: 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.H IGHE T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) s B- / (o-D � 3-D� � 3 0g � ��3� ,.-►a��� � 46-AIJ, SA?ukt7tP L5. w-F 09-1y. A-OfS . /S' OR C'S B- r—ill ' B-.Z 9.5 ' . b 3. 6 cvfe Z lk I,A+4,vy F �� ok•�1 kvtS 07.08' 5?,e,4y ,P e- -O i B- D w *.''L` CIAt O Cki � p Y DOj s " v -Ml , � P3' 951 B- p 3. f i Mp7V&IP B- � f y-Tsv s: Sl vO �►�c1f:��S 1 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 I PtHlvu PER INCH P- P_ 57. 4 i ov i.t7 s ST Tom" O Gv P- !LU 6-- i S 6-C TD k- i ecT�o 71 it Z9,Q v-t.- P- f- O M <q PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or di a�cLes. Desc J n ^ < zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all b iit and t dirrcl *ad nt ` �, of land slope. SYSTEM ELEVATION A _. _ _ I 461 � D� 1 �ThSs hest site . � ,. - ._ r eo ionat s�pt(c s rs� rrr I (._ 1 z _ _ or ion .j ._....... t _7 _ _$' e1 � G�� � � Q t 74 c, _ Ilk I _ �.. -7 v t ; IS E i • `� 2-11 E 3 , c L �1,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: HOMESITE SEPTIC PLUNIBING CO. /¢1IC/r 2/_l Qga ADDRESS: CERTIFICATION NUMBER: P ONE NU BER(optional): ROBERT ULBRICHT OZ�P 2 — ��. XP5 NO, 3307 WAS s-S NN.INSTALLER&DESIGNER LIC.NO.001543 CST SIGNATURE: GGt7,,i DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5595 , v To be a complete and accurate sail test,your report must include. 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is tbis a new or replacement systeln; S. Complete, the Suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE rase the abbreviations shown here for writing profile: descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A sf>pazr<ate shnet inay be U. ;ed if desired; 3. Make sure your benchmark and vertical elevatior reference point are clearly shown,and are permanent; . Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tic>r'€, i1 aappropriaate; 10. If the inforniat on (,iuch as flood plain,elevation) does not apply, place N-A,in the appropriate; box; it. Sign the fcx m and place your curl ent address zinc! your certification number; 12. !Ivlaarc legible copses arl(I distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols s! -- S onw lover 10"') BR Bedrock c,ol3 - Cobble (3- 10") SS - Sandstone gr Gravel (under 3") LS - Limestone *; _ Sawi HGW -- High Groundwater r ,'a��+e ,dl Parr Per -r,hmion Rate rvr :.r3eciiura, 1'q F>tE.>r; ..._ Fine Sand Blrtp - 13,j ldfng , Loarrly sand \,� - Greater Than x � % sl _.. Sandy Leap;,-,.a Lr.ss Than d _." Lo am Bn _.- Bmvvn, *sil Silt Loam BI Black si -- Si l': G - Cray d - Clay Loan-i Y Yeilo� So Sandy Clay Loam R -- Red sic! - Silty May Loarn not - Mottles sr� - Sandy Clay -- th sic - Silty Clay fff fester, line,faint 11*1� Clay cG cnrnrlsora,coarse ct P�:w' nim - Many, rrtediurn r'n - Muck d - distinct is pronninent HWL - High water level, Six general soil lextrares surface water for liquid waste disposal BM Bench Mark VRP - Vertical Reference Point T 0 THE OWN ER: lest repori is the first st p in securing a sanitary permit. The county or the Department may request e3, trJs soil ,r st ;x, thI -, fi id prior-to permit isse,arace, A complete see of plans for the private d a permit -�pplicaci m must be sr-braait'ted to the local arathority ire order to [he 'aa ,'-H v ur.mnt rnlist.b C3lutained and po{ Led of for to Ql`lte Start(J ally ct7r7ctE11e;t1:2rt„ DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUS7'tiiY„ DIVISION LABOR'AND PERCOLATION TESTS (115) P.O. BOX 7969 FJUIVIAG�!PELAT`IONS \ / MADISON,WI 53707 (H63.09(1)&Chapter 145.045) LOCATION- SECTION: TOWNSHIP/A4li*@H-RMY: LOT NO.:BLK.NO.: SUBDIVISION NAME: s�Y°�,C 14 17 /Tz9 N/R/9 E ( )W �fU04e>v Prt-�° o R 4c-tt5 COUNTY: OWNER'S gUnPER'S NAME: MAILING ADDRESS: ST, cool K (JRO PI?&q W6- 11W . tf A7 , 0,0 W IS . SV61Ce USE DATES OBSERVATIONS MADE NO.BEDRMS : COMMERCIAL DESC�R/IPtTIION: PROFILE DESCRI�PjTIONS: O ATION TESTS:Q / 1:5�j !'/�VU4,/ c Viet ❑New Replace I /L/,¢y 1 Q +TV AJ E Z ' 71 1� RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) s ❑u EIS ©u ®s ❑u s ❑u ❑sou /ti G.�ovw ��Ss��e� .� Of 771tu1c f`01 .MAlEfi4L5 fag 7VP SdiL If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: C//F SS _ Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS iv aW4ot'14RI fee(-- BORING TOTAL DEPTH TO GROUNDWATER-IN 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- /0.0 9y<o� " ' i fr ,Pa //�,, •ls' 8N s f,�i , z.s�' Teti s, . la ' 8•►No of C/# /o 4n (-r-W, w . Im4 viS>i uc T / . PAP- tiO-1S B- > /0,0 _773-3 /rho B- Z, kv,0 -7 zo�o-00, 7 l6lo ' L . S/ i# /33 ' :�F � ' �/ fj�� y B- 16-5 /too. S-6 ?�.. � /C�, $ ' �b' 13N � , i7 � � � ' " Q CS �� PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN( AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH P- / • 2 Z S C o f_rf P- ,t, v �. P- y 3 s . ?� / / n1 _-J- 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. ` fr SYSTEM ELEVATION /yY — I ( € ) ------- _ e APP falf 4nt tN AO A E i q S �►0 ''t°�` IOG� 0 fr T� f0 '( a �y fi 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: /� HOMESITE SEPTIC PLUMBING CO. cTV�� z 1 %99G ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(o tional): ROBERT ULBRICHT A6 ..�� WI&MASTER PLUMBER 1:113,NO. 3301 M.PR-Sr.MINN.INSTALLER&DESIGNER LIC.NO.00663 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — ' REPORT ON SOIL 13ORIN &S ; PERCOLATION TESTS IIS Pao'sr PLAA1 PROTECT r. D. �- DA rE - - li� E )L s17 T2 y,�ly , -T, CROI x or/ HOMESITE SEPTIC PLUMBING GO. BOB ULBRl c,'..x RE 3OWEIL RD.:HUDSON: WIS.54016 / ROBERT ULBRICHT Q ii WIN.MASTER PLUMBER LIC. R LIC. 7.006 3 C %�"" f✓V O - MINN.IN9TALl�R&DESIGNER LIC.NO.00663 PROPOSED mom mosr LIE 2.5- Fr. o f mete APOM .4Lz- TEST . Iw.4S. p POSE O WL u M VSr LIE 5o FT ae /MORE' F,POH fit[ TEST �,PEilS, 0 " Bi¢ elloE PiTs O = EJP'ifT/�11(r WELL • s Yow;z . B M _ VE�tic,,~� .PEFERtwcE- PoiaT i iy~ 5>f1l1*.1zc PAQ .a� y�hoE F/�v.+rTio vS Se f CS% 47' rop,+„4,.A�- LEGEND 6 1EVAr0w of 11&r ,pEi. .00. O ' cvlsrE p I I s%/vE,e p1y1jVt1 AP yam. g2pLooX i Fjclof�( v I RAW I i f f}SA�i!/T�D � O o� � o nU-v,0 - TM OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUS TR Y Y,, INDUS DIVISION LABOR.AND C P.O. BOX 7969 ,HUMAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707 (11-1163.09(l)&Chapter 145.045) LOCATI N• , SECTION: TOW NSHIPM*WN�@+P7k TTY: OT NO.:BLK ;is UBDIVISION NAME: sfY 5,014 17 /U? N/R/q E( ►W I}00.rbN P � Co /}G�5 COUNTY: OWNER'S 'S NAME: MAILIN ADDRESS: t►f.9 �S sy�� Sr coo 0(X 00 PAPF 2 5f6- 4400*7' //40/. If 'r• / R UPS OA1 J USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL ❑ ce DESCPROFILE ❑ R S STS/: w Replace _/ � MAAJu4,V' � IFo f..t , X151/ Sybo/s� .Z •P/ooze .A"PdAvS . RATING:S=Site suitable for system U=Site unsuitable for system rNS ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S S EM-1N-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional)OS 0 of 3;) &j I— Fill 1+11t0/+4t5 -FOAL TO diL. If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: _-17 Floodplain,indicate Floodplain elevation: r PROFILE DESCRIPTIONS mo JZP,t.+•M M fee'f- BORING TOTAL DEPTH TO GROUP DWATER-IN - CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED S . ! HE TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) 9�/a�ii�D •75' 2W S f�/l 1 Z-SP' B- ��,fJ /��0� C4 /V 411 (TrW w. fN v X -Pis liodr B- 5, " -r+V ut ey s G4 • ' Del' N . + , •33 hW B. .� o.o 77, • 7114uw "y / • ♦�1 C .V J B. 11,o S ��• Sao - �f✓ .7 ' /b ' 6, PERCOLATION TESTS TEST DEPTH., WATER IN HOLE TEST TIME DROP IN WATER LEVEL-IN HES RAPER INCH MINUTES NUMBER IN( AFTER SWELLING INTERVAL-MIN. p D P p_ Z d- z— F i^ a P ' A ' P- y s S . P_ , 1 A 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 _ tN j l . U -_1, { , 7- 177 1,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: HOMESITE SEPTIC PLUMBING CO. 17,04JIJEE, P. I ;—QGG ADDRESS: CERTIFICATION NUMBER: PHONE NUMB Rlo tional): ROBERT ULBRICHT zy�'L WI&MASNR PEUMBER 1:113.NO.3301 MARS CST SIGNATURE: MINN.IN9TAUR&DESIGNER LIC.140.®0663 DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — REPPIRT ON SOIL SORM&S PERCOLATION TESTS IS Poor PL.gN pRosEc i r. D. -WO APM DA rE 'M cRoix Or/, HOMESITE SEPTIC PLUMBING CO. BOB ULB'kl cii i RT.3 O'NE;L RD.;HUDSON;WIS.54016 C S T .y�Z ROBERT ULBRICHT WIS.MASTER PLUMBER LIC.NO. 3307 M.P.R.B. MINN.INSTALLER&DESIGNER LIC.NO.00663 PROPOSED mom mosr 6v 2-Jr Fr. TEfT Aec.45, PRo QDSE o wea M osr LIE 50 FT O,e /yp�E FiPOf? ALL TEST �j,PE/jS� • = eAce*F Pirs Q = Err'isr1Ai!r !.DELL X ' �EQG /oCg7"�DN/f s AUP Adl-rkCP o,Q S�arlfL /,�ES T� e 1! , • ` /,/o fez . B M = f� E ® = VFRric,4t ki-ACRiVei - Poi4r- l kl a 941y��xzvk p �4T r0 0 ti S/ rF'� LE GE N D tVat APEF. -00, p . wdsrE ��PoAVCr I Pip D ��iiS �� gPP�oX FgcTo#Qy I R4,W A)VN I � I f{ { I 1 i O TA ( Z: 1 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTi'Y,� • c DIVISION LABQR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1) &Chapter 145.045) LOCATION- SECTION: TOWNSHIP/MW4IeI ALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: sf L E '/4 !7 /Tz9 N/R19 E ( )W RLi0�t,,v .711 61/f ,4' Ac�x COUNTY: OWNER'S l!»ER'S NAME: MAILING ADDRESS: ST CPO r X 0,00 PAIAIR J3,fG Itmvllflo' //cvy 4 X Tr / �uDSc � W i S Syd/fin USE DATES OBSERVATIONS MADE NO.BEDRMS : COMM R IAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:: ce Ism MAAJU-�.A('1Q141.R ❑New Replace I ;e1�J' ? / — e T(,tu E 1 n f,•.�/nyz fs fb/y/ 9' S'�va/S, 1 RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDINGTANK: RECOMMENDED SYSTEM:(optional) ®s ❑U [--Is au o S ou o S oU o Sou Of yC NS C" Fill )t A'1c P%'4( S frA_ TOP Sd,'L- If Percolation Tests are NOT required DESIGN RATE I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: C'M'j 0 Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS /" 11)-E'.k._."tA I ff'c!'+ - BORINGI TOTAL D PTH T GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHE T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) qC, / � •75" By -5/ B- ��•Q //•CCCr �'t� /o An {T1u w . DiY7�u<T fie^ oaf'- NOS; B- B- e,p (1.s - B- © 5 O�" -7y i"r� ,�� T 4 N Si u 1C�1 7r L"i4'l /G'7�"' / �1•S B 14t) dry y C-5 - PERCOLATION TESTS kTE DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES INi AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PER PER INCH Z-- Z �'A 7,-/3 z � � � 401Z </ /,ES I A V PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the horn 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 i l 14 rt/f C.", t i i r k OT is 6s# sitePiRaVEa for a conventional septic system. � N , , i / E l , . i 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: HOMESITE SEPTIC PLUMBING CO. SU.Uc .— 1 /967G ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(o fional): ROBERT ULBRICHT 2�IP2- ' 'x Mg.MASIER PLUMBER 1:113. NO, 3307 M,PR_& CST SIGNATURE: MINN.INSTALL.ER&DESIGNER LIC.NO.00663 - DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — r'r7Crt ,G o7 -1c - �EPOIZT ON SOIL BORINGS PERCOLATION TESTS 115- PLOT' PLAN pRoTEc i r• D. TWO API-4 A44 off . DArr � - ' - /lam k 54% ST, C p o(x or/ HOMESITE SEPTIC PLUMBING CO. BOB ULLRl cii i RT.3O'NE.L RD.:HUDSON:WIS.54016 CST y�Z / ROBERT ULBRICHT WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.& O MINN.INSTALLER&DESIGNER LIC.NO.00663 , PROPOSED HovsE MUST LSE 2� FT. O� Mo,?E "a-4f •9Lt. TEST ^ec-45. PRo POSE C WELL M Vsr LIE Sp FT o,e tip�PE FiPOr1 ,�cc TEST �iPE�S, • = gAce*C Pir3 O = zx/sra6- WELL A01 e.e 0 of 54.&WcL /,�ES r ` li/o, 2. . BM ° ��E ® - VF,fric'#,- kEFERtwcE poiw- iy %011f-viz%c se f CS% 97' r6.At V,.,e- LE GE N D e/EVAroAv of 110r Pr. Leo, O w�srE pQoaxr 12ewv APPRdr' D f'1a0� soil S :DURC FICT°Ry �3 ✓ (MIN POC ti Aspy.��Eo o o 7j-4 -s ST. CROIX COUNTY WISCONSIN r ZONING OFFICE b 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 June 25, 1986 DivZ6-i.on of Sasety and Bu4ldingz Buheau o6 Ptumbing P. U. Box 7969 Madizon, WI 53707 Dean. SiA: An on 6 to inve6ti,gat on bon the Durso Bag pnopeAty, toca.ted at the E2 o6 the SE% o6 Section 17, T29N-R19W, Town o4 Hudson, St. Ctto.ix County, teveated zu-itab.E'e so.c Pis at a depth ob 10.5 beet, beeow which zeazonab.te high gtcound wateA wab noted. This .6 to shoutd be 6uitabte 6otc an .in-gnound pnezzuAe .5y.5tem. Shou.E'd you have any questions, p.tease 6ee.2 6tcee to contact thin objice. SinceAet y, Thomas, C. Netson A,se,ustant Zoning Adm.ini stAaton TCN/mj STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township/}M(X W4WW, E% SE kJS 17 IT 29 N/R 19 AXWW Huctson St. Cnoix Street Address: Subdivision: County: Landowners Name: Mailing Address: Vuh.o Bag Rt. 2, Hwy A, Hudson, W1 54016 I (We) , the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises are not suited for a conventional private sewage system. If approval is granted , I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved , the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. Signature of Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY OF This day of 19 Notary Public, State of Wisconsin DILHR-SBD-6413 (N. 05/81) My Commission Expires: WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 79699 MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St. Croix Location k Ste_ 1/4, Sec. 17 TT_N, R�_"pt7) W Town Hu6on Street Address Lot No. Block _, Subdivision Landowner's Name: Vuno Baq The application for this site is for: ❑new construction use. ®replacement system use. If this is NEW CONSTRUCTION USE, the alternative private sewage system is: �.1to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota numm ers ssueU-1—oyou.) t. lone of the applications needing a quota number. The quota number assigned to this application is - - ❑for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. D for an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. (._.]for an application on file prior to February 1, 1980. (_]for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: 0 a failing conventional soil absorption system. a holding tank that was installed and in use prior to February 1, 1980. ❑a privy that was installed and in use prior to February 1, 1980. If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a conventional private sewage system, check here.0 I certify that the above information is true and accurate to the best of my knowledge. Name Thoma6 C. Ne.Uon Si re County Official Title Aar iAtant Zoning A&ninjstAato& Date June, 22;, 19RA DILHR-SBD-6158 (R 12182) z cn H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a OWNER/BUYER Duro Bag Mfg. Co. (Shorland Enterprises Inc.) M ROUTE/BOX NUMBER P.O. Box 247 Fire Number CITY/STATE Hudson, WI ZIP 54016 PROPERTY LOCATION : ' , s Z k, Section, T�N , R�9 W� Town of zV204Vp/ St . Croix County , Subdivision]&T or �i�s„n�Tit;.�t� Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St . Croix. County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1 , 1978 . St . Croix County accepted this program in August of, 1980, with the requirement that owners of all new systems agree to keep their 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , 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 . 0 0 I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Off ithi 30 days of the three year expiration date . SIGNED DATE St . Croix County Zoning Office P. O. Box 98• Hammond , WI 54015 715-796-2239 or 715-425-8363 n__ dare and return to above address . 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 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 Du ro Rag Mfg Co (Shogland Enterprises Inc ) Location of Property ,� LE 3L, Section T N-R� & Township Town of Hudson Mailing Address P.O. Box 247 Hudson, WI 54016 Address of Site County Road A . I Hudson, WI Subdivision Name NONE Lot Number Previous Owner of Property Leo Germain Total Size of Parcel 68.498 Date Parcel was Created Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes X No Volume l w and Page Number a 03 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) cekti6y that ate b.tatement6 on thi,6 6onm ahe tAue to the bebt o6 my (oun) hnowtedge; that I (we) am (ace) t1te ownen(a) o6 the pnope4ty daembed in .th,i,a .in6o4mation 6o4m, by viAtue o6 a waAAanty deed tecotded in the 066.ice o6 the County Reg.izten o6 Deed6 a6 Document No. a 99,3 ; and that I (We) p4uentty awn the pnopoded zite bon the sewage dispozat byd em (on I (we) have obtained an ea6ement, to nun with the above duchibed ptopenty, bon the constAucti.on o6 said eya.tem, and the Game has been duty necon.ded in the 066.ice o6 the County Regi6ten o6 Deeds, ae Document No. I . SIGNATURE F °�e� �� ' SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED REPORT OF INSPECTION - INDIVIDUAL SEWAGE SVSTtM San.i..tany PeAm•i.•% State Septic TAME Towne.hi,p St. Cnotix Cuun•ty oc .ion csorf_ s C Sec-ti.onga_Lot Subdi,vi.ei.on .I PTIC TANK Si z gatto nd Numb et o.6 compaA.tmente ,ietance 64om:, Wett Bui.td.ing 16 12% atope HighwateA 'LIMPING CHAMBER Size gatton4 _ Pump M en Mudet NumbeA OLDING TANK Size 9attone. Wu be Fsui ompan.tmen•ta Pumper y a m ie.tanee 6Aom: Wett t di ng` �! 12% e tope__ Hi.ghwate t 8SORPT10ON SITE Bed X 7Aeneh e.tan ee 6Aom: Wett 41-o-e?t Bui,tdi.ng .7 7 12$ Hi,ghwaten IiSORPTION SITE DIMENSIONS Width o6 tuneh 6t Requ44ed anew_ Length o6 each tine 3() 6t Depth o6 Koch betow tcte x.n Numbers o6 ' tinee 3 Depth u 6 noeh oven To t.aX teng.th u6 t.inee_ (� 6 t Depth u 6 ti.te below grade--_�-8 _r4 n D.ie.tance between tinee G At Stope u6 •tAench ' 4,a . pen 100 At > 1 u 4 u. abo u�4N.t.iun 'aneu 6t Type o6 Co veA: Papers u e•tAa "' if DIMENSIONS- Number uj- pi:tb a Y around p•i.te yee nu Outei dg di.ame,ten Totat abookpti,on area 6t .Area Aequi-ted 6t NS PE TITLE 11PROVED � VATS Z211/ 19 8 'I JECTED DATE 198 'I ASON FOR REJECTION EH 115 Rev.9/78 REPORT ON SOIL BORINGS AND Efto �� S ', WISCONSIN DEPARTMENT OF HEAL H*ND S(fC"[#_6 /ICES t P.O. BOX 309,MADISON,W NSIN�6� Ott�Ce LOCATION,!2�'/o, '/o,SSe�cttiio�n, Z ,T�N,R/9-f gr)W,Towns ip 610.icipality S Lot No. °� ,Block No. ;�I ` �/C C Subdivision Owner's%Buyers Name: 1t-= 9 Z' Mailing Address: �3� L 4– TYPE OF OCCUPANCY: Residence No.of Bedrooms 1 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW —REPLACEMENT ALTERNATE SYSTEM—OTHER OTHER DATES OBSERVATIONS MADE: SOIL BORINGS It,/6leo PERCOLATION TESTS �/ /e,(cg d SOIL MAP SHEET �� NAME OF SOIL MAP UNIT U PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL,INCHE RATE NUM- SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P_ % 6A Y/4 3 Y8 3'/i` 1 P— P— P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- 1 8� O >84 i- -5 L G 8,S L ZG• Bn S 5-7 B- 2- zo o > / Zo c. S B S,L.47-•Bn R On 5 6r2 �. B- Z > 9 L Qk N, S c el • SL /0 5 6R B- & 4 Ni 784 r_ L 'S4 t tZ L 4-' e G B- S I o c y // L 5" S,L !3 L S �e L8' 5 ,c PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the Ian the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ��� �- F7- � -.Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. ' >L F__ O F f'SOU N Ib e 9 :q CIO R T 3 , E E �'' ,� ►• �{�, 1.o _ � _ T - r s - E e V ` e e i i. _ vLl I t�1. ��E ,►� ` 4 �e, L.LC---� � 0 ;ESE Z8. E F s sm 0�01. - Is�, � �......_,�,...„,�.._ e P..m�...�.,�,. .mom....,m�.._ .,.�. .,,�..�.. ......,..,�,a.... . .._. Pro. ..,�,.w.., _,..,.,e._ ..e,._ ,.�..�._...._.».aa-..,..., .,....-. ....®....�e..,�.�,�..,.�..�.�,».._a.m._..,.,b., I,the undersigend,hereby certify at a soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administ tive e,and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print MT--- �- V ��F-E Certification Address `s .Name of installer if known Copy A—Local Authority CST Signature REPORT OF INSPECTION- INDIVIDUAL Sl:,IAGE DISPOSAL SYSTEM Sanitary Permits 0' State SepticD NE TOWNSHIP St. CroiX- County SxPTIC TA'?IC Size �_� gallons. "4umbe of: Conga ments Distance From: Well ft. 12% or greater slope —A-14ft. Buildin t. Wetlands f: Ilighwater ft. DISP©SAT.. SYSTF, 2 Tile Field or Seepage Pit(s) Distance From: TTell ft. 12% .or greater slope N ft. Building, Uft, ' Wetlands FIELn Highwater ft. Total length of lines �ft. Number of lines Length of each line ft. Distance between lines ft. Width of the trench lam ft. Total absorption area (07 sq. ft. Depot of rock below the-+ in. Depth of rock over tile .Z in. Cover aver rock `�S Vi i) Depth of tile below grade Ic n. Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ft. Number of pits Outside diamet ft. Depth below inlet ft. Gravel around nit : es. '! n . �y j Total absorption area sq. ft. Square feet of seepage trench bottom area requir9d _ Lie ( r t:quare feet of seepage nit area r quired 1 Inspected Title : Approved Date T I`7-297 . Rejected Date -197—. B' 2-State and County State Permit PL67 Pe rmit Application County Permit # _ O for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED 11-7-Date Approval Received from State if Required State Plan I.D. # A. O TER OF PRO ERTY Mailing Address: 4/ I Zee 2,e B. LOCATION: SC '/4 Si5 '/o, Xection /�� T n RE r W Lot# City_ C7 7 Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex o. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES_NO # of Bathrooms—_ Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation x Addition_ Replacement_ Prefab Concrete *Poured in Place Steel Other (specify) F. EFF U NT DISPOSAL SYSTEM: Percolation Rate 1) 2)�3) Total Absorb Area sq. ft. New Addition Replacement *Fill System See age Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches See age Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Ce ' ied Soil Tester, Cep , O NAME ' ` C.S.T. # J�" and other information obtained from (owner/builder). c� Plumber's Signatt) MP/MPRSW# 1 Phone # Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). i i Do Not Write in Spa elow FOR DEPARTMENT USE ONLY Date of Application Fees Paid: State Xnl e419 County ���`- Date vL� Permit Issued/Re} e —(date) Issuin g Agent Name 1 Inspection Yes No Valid# Date Recd 1. county ( ite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI 53701 state (pink copy) 4. plumber (canary copy) Revised Date 6/11/76 Mr. Roger Johnson Page September 22, 1977 6. in the event installation of' the plumbing improverients or system has not con—mnced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work r4ay commence. In granting this approval , the [Division of Health does not hold Itself liable for any defects in plans or specifications, plan omissions, examination oversight, construction or any damage that may result In or after Installation and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Chapter H 62, Wisconsin Administrative Coda, requirements. It shall be necessary to obtain and fulfill the permit requirements of the city, village, township or county in which this installation is to be constructed. failure to obtain local permits will automatically void this acceptance. By order of Ralph L. Andreano, Ph.D., Administrator, Division of Health. Sincerely, James A. Sargent Chief JAS:JQ:skk enc. cc; Mr. Erbert Derthold, DPS - District 6, Eau Claire �4r. Harold C. Barber, Zoning Administrator Duro Paper Bag Manufacturing Co. Septv.L iber 22". 1577 Mr, Roger Johnson 1919 North Su-nit Avenue Plan identification No. 77-04156 Milwaukee, WI 53202 Dear Mr. Johnson: Re: Ouro Paper %. 9 Manufacturing Company Sewage Disposal SE TAP SE 1/42 Section 17, T29N, R19W Town of -Rarth Hudson, Wisconsin St. Croix County Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes, and Chapter H 62, Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon compliance with the stipulations Indicated on the plans and the following code sections. Please review your code for the requirements of each code section noted. 1. H 62.04 (4) (a). Gradient of sewer. 2. H 62.04 (4) (b). Depth of sewer. 3. H 62.20 (2) (c). Replacement system area required. 4. H 62.20 (2) (b). Percolation and boring tests. 5. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the deportment. Mr. James M. Burkemper Page 2 October 26, 1977 d. In the event that this variance creates liquid waste problems at ground level or any other operational or maintenance problems occur the provisions necessary to resolve these problems shall be commenced upon receipt of approval by this department. In granting this approval, the, Division of Health does not hold itself liable for any defects in plans or specifications, plan omissions, examination oversight, construction or any damage that say resilt in or after installation and reserves the right to order changes or additions should conditions arise making this necessary. In the event installation of the plumbing improvement or system has not commenced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work may commence. By order of Ralph L. Andreano, Ph.D. , Administrator, Division of Health. Sincerely, James A. Sargent Chief JAS:JQ:kms cc: Mr. Erbert Serthold, DPS - District 6, Eau Claire Harold C. Barber, St. Croix County Zoning Administrator Duro Paper Bag M nufacturing Company October 26, 1977 Mr. James M. Burkemper 12545 W. 3urleigh Road Brookfield, WI 53005 Plan Identification No. 77-04156 Dear Mr. Burkemper: RE: Duro Paper Bag Manufacturing Company Request variance from the 42 inch maximum depth of the se SE 1/4, SE 1/4, Section 17, T29N, R191 41 Town of North Hudson, Wisconsin On St. Croix County I-CA 49 Approval; Variance Based on Section H 62.24 Wisconsin Administrative Code Application: Section H 62.20 (2) (b) In accord with Section If 62.24, Wisconsin Administrative Code, a v e is hereby granted to Duro Paper Bag Manufacturing Company. This approval is for the variance requested of 66 inch maximum depth of the proposed system. This approval is for the variance requested only and does not include review of the design and size of system. This variance is subject to the following conditions; 1. That any locally concerned authorities 'having the responsibily of enforcement of local ordinances permit the installation as proposed. 2. The system be installed and located in accordance with Section H 62.20, Wisconsin Administrative Code, except where this approval grants exception to these rules by this variance. 3. This approval is based on Wisconsin Division of Health requirements. It shall be necessary to obtain a state septic tank permit and to fulfill the permit requirements of the city, village, township or county. Failure to obtain installation approval from local authorities will automatically void this acceptance. W 1 .15 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON,WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION:S-Z• %,5- '/4,Section 17.,TZ9N, R A9 4(or) W, ownship or Municipality 90�--�a—✓I Lot No. Block No. County S 1 C `r n`X Subdivision Namg Owner's Name: v v'o p4 +`=/`r 1�0`9, /Y� Q G o Mailing Address: S L4 Ol G / TYPE OF OCCUPANCY: Residence No.of Bedrooms Other 1- ���� ✓�d S�—r t EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS ��� 5�'�� PERCOLATION TESTS —7 7 SOI L MAP SHEET � 'Z I_I_ � � � SOIL TYPE A V's-011 PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE CHARACTER OF SOIL NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P_ J (0�I S=&— LD t A) D 5' SCCro 4�a 1�JV✓► P-3 So 1� 1 .5 ll)a esT_ H rum( SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B_ t o N®o k oo zu 11 ) 9 " s, "Si L40 tt S �t oo " _Z " 'I Si' �e 'I C .S. B_ U Al B- �14�i� �� PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suital�Ireas. Indicate number of square feet of absorption area needed for building type and occupancy. )(0 5"(D Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. O C Gam° � O G S 0 LO j Gov` i r 0 n o � � i .v 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 location of test holes are correct to the best of my knowledge and belief. l/ Name (print) ,Adc4 Certification No. Address R07 0q _5� v c�CG✓1 W�'S S�'� D l�. Name of installer if known �� CST Signature C � CAL AUTHORITY a r-11 al W6 State of Wisconsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH MAIL ADDRESS: P• O. SOX 309 MADISON WISCONSIN 63701 IN REPLY PLEASE REFER T0: 61, 1t" SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS 29l! R# Sojoif Av"a Plan Identification No. l 7 ULINSIA"t V1 R�G�t�F�,� -� . Dear Sir: � SE 1pN\\iG OEEItE �� Re. gog,r► F"Or SM 1 /.-4 - i A WA WA am. 7 T290 19U Tom of R e Rud (Sr. Croix t This is to acknowledge receipt of your plans and specifications for the above- indicated project. When referring to this plan in the future, it will be absolutely necessary to utilize the plan identification number assigned to the pro ect. The spaces below indicate if proper fees have been submitted or if more information is required. Providing plan review is not completed within thirty (30) days, a permit to start construction may be issued if requested. See Section H 62.25, Wisconsin Administrative Code, for limitations in reference to permits to start construction. Preliminary plan review for determination of fees does not hold the department liable in the event additional fees may be required upon complete plan review. Preliminary review indicates the plan review Fee required is $ /`? Plan accepted for review. Fee received is $ 1�i - Fee is being returned because of II Overpayment Underpayment. Providing one of the two categories above is checked, please remit correct total fee in one payment. Indicate plan identification number on remittance. No fee has been remitted. Plans submitted with no fees will be held in abeyance until remittance is received. Indicate plan identification number on remittance. Additional information required. See attached Plb. 100. The permit to start construction will not be issued until 30 days after requested information is received and accepted. QPlans being returned. See attached Plb. 100. Sincerely, asses A. arg Chief JAS:fjs 3/70 PROJECT DETAIL DATA SWEET 1 NAME OF BUSINESS - fff AVV Co LOCAT l ON (}V .�. PJ QF VY '. S� street or highway city or township county LEGAL DESCRIPTION � _� �/ k G TTTTf--� 1� � T�� � ^� OWNER _�1 4.0 u �cTu�I _��� Mai 1 ng address -Noes 0*46 . .hY LJOW ' Z I P ARCHITECT OR ENGINEER 42.wAddress IZ545 (A.) ee �_. Z t P S 30 tl,5 PLUMBER A Address -" ZIP 1 . Check appropriate building usages) 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) ( ) Dining hall . . . . . . . . . . . . . . . . . Per meal served Toilet waste Yes No ( ) Motel ( ) Hotel ( ) Cottages . . Number of units : 2 persons/unit i Nci•w11aiu11iL TOTAL 9Uii8Ek OF UNiIS ( j t,hurches . . . . . . . . . . . . . . . . . . . . Plumber 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) _ ( ) Retail store . . . . . . . . . . . . . . . . Number of employees Number of customers Ti0-sq. ft./person) ( ) Service station . . . . . . . . . . . . . dumber 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 X I Automatic clothes washer Yes r No x Automatic potato peeler Yes Other (Specify) ft udc+-`_-R---_ No � j, 3. Fill in the appropriate information for the following as indicated: Septic tank capacity planned ./000 L Percolation test results - ATTACH-PERCOLATION TEST AND SOIL BORINGS REPORT SHEET RECEIVED C0111"!ETE OTHER S I DEE AUG 3 0 1977 PLL)MPt"', SF�^T�n►.1 Seepage trench bottom area planned _ width linear feet depth ' Seepage bed area planned It width linear feet _3 depth Seepage pit planned outside diameter depth below inlet depth 4. See approved plan for specifications and details. Signa a of rson com ting form: STATE DIVISION OF HEALTH, PLUMBING SECTION P. 0. Box 309, Madison, .Wisconsin 53101 E _ Approved: Addres 2,I Date: I�YI ZIP 3 Z ? THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIREMENTS AND DOES NOT EXEMPT THE Date: �I INSTALLATION! FROM CITY, VILLAGE, TOWNSHIP OR COUNTY PERMIT REQUIREMENTS AND SHALL BE VOID IF REVISED WITHOUT THE WRITTEN APPROVAL OF THE DIVISION OF HEALTH. DEPARTMENTAL USE ONLY State of Wisconsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH MAIL ADDRESS:P.O.BOX 309 September 22 1977 MADISON,WISCONSIN 53701 P • STREET ADDRESS: 1 WEST WILSON STREET MADISON,WISCONSIN 53702 IN REPLY PLEASE REFER TO: SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS Mr. Roger Johnson 1919 North Summit Avenue Plan Identification No. 77-04156 Milwaukee, WI 53202 Dear Mr. Johnson: Re: Duro Paper Bag Manufacturing Company Sewage Disposal . SE 1/4, SE 1/4, Section 17, T29N, R19W Town of North Hudson, Wisconsin St. Croix County Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes, and Chapter H 62, Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon. compliance with the stipulations indicated on the plans and the following code sections. Please review your code for the requirements of each code section noted. 1. H 62.04 (4) (a). Gradient of sewer. 2. H 62.04 (4) (b). Depth of sewer. 3. H 62.20 (2) (c). Replacement system area required. 4. H 62.20 (2) (b). Percolation and boring tests. 5. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. Mr. Roger Johnson Page 2 September 22, 1977 a 6. in the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work may commence. In granting this approval , the Division of Health does not hold itself liable for any defects in plans or specifications, plan omissions, examination oversight, construction or any damage that may result in or after installation and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Chapter H 62, Wisconsin Administrative Code, requirements. It shall be necessary to obtain and fulfill the permit requirements of the city, village, township or county in which this installation is to be'constructed. Failure to obtain local permits will automatically void this acceptance. By order of Ralph L. Andreano, Ph.D., Administrator, Division of Health. Si �• 1 James A. Sargent Chief JAS:JQ:skk enc. cc: Mr. Erbert Berthold, DPS - District 6, Eau Claire Mr. Harold C. Barber, Zoning Administrator Duro Paper Bag Manufacturing Co. PURPORT OF INSPECTION--11DIVIDUAL SE 4AGE DISPOSAL SYSTEM Sanitary Permit .,?F Stat Septic g, 1AP?E TOWNSHIP t. Croix of ty S^"TIC TANK 'Size gallons,,- ber of Compartments Z- Distance From: !Jell ft. 12% or greater slope ft Building ft. Wetlands ft I7ighwater ft. DISPOSAL SYSTEM Tile Field or Seepage Pit(s) Distance From: T,Tell S ft. 12% or greater slope -----it AA*A Building � _ft. Wetlands ft FI .:LD Highwater - ft. Total length of lines b ft. Number of lines. Length of each line ft. Distance between lines 6 ft. Width of the trench ft. Total absorption area 1,F441 -sq. ft. Depth of rock below tile 1-4n. Depth of rock over tile Z- in. Cover over rock Depth of tile below grade in. Slope of trench _ Z _in per 100 ft. Depth to Bedrock ft. Depth to ground water PITS S La Number of pits Outside diameter ft. Depth below inle v ft. Gravel around pit : yes no. Total absorption are g d sq. ft. Square feet of seepage trench bottom area required Square feet of seepage pit area required -r--- Z� Inspected by: O(Z000 E-LJ LS Title : Approve , Date 197 . Rejected Date 197_ •PIb '61. State Permit # < Permit # Permit p ica.���. •� - ��Y for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: '/4 ` '/<, S ionN, R E ( r) W Lot# ity_ Subdivision Name, n rest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms_ Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY � Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement— Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft. New Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope 1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME C.S.T. # and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW# Phone # PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). ' k k _� k _ _ _ _ o _ + e a i r J � E k k , + r r , i r k ; E � 1 + _ 4-- _ f �.. _. i _ _ _, f _ i a + i 1 i i f + i E t k i 3 t k E 1 t Do Not Write in Space Below ^� IFPR DEPARTMENT USE ONLY Date of Application � I–f 6F`/ (p Fees Paid: State County D C Permit Issued/Rejected (date) �� `2z- /„ Issuing Agent Name Inspection Yes No Valid# Date Recd i county (white copy) 3, owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 4. plumber (canary copy) Revised Date 3/1/75 -State of Wisconsin \ DEPARTM EALTH AND SOCIAL SERVICES 9 ' DIVISION OF HEALTH w..7 MAIL ADDRESS: P. O. SO% 309 0) MADISON, WISCONSIN 53701 Wareb 9, 1976 IN REPLY PLEASE REFER TO: SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS AMCCS Jam" X. . BiMNS. T�1„r, \ entification No. 76W53.3 1.2545 W. D=2 S Sre 111UM, V1 $3005 Dear Sir: Amro Pic Bsg l�m�dalet�c� Re: t $17 TM 5M. NOftb WA48M Toweahipt St. Cs'ots COMMP 11wage s1 This is to acknowledge receipt of your plans and specifications for the above- indicated project. When referring to this plan in the future, it will be absolutely necessary to utilize the plan identification number assigned to the protect. The spaces below indicate if proper fees have been submitted or if more information is required. Providing plan review is not completed within thirty (30) days, a permit to start construction may be issued if requested. See Section R 62.25, Wisconsin Administrative Code, for limitations in reference to permits to start construction. Preliminary plan review for determination of fees does not hold the department liable in the event additional fees may be required upon complete plan review. Preliminary review indicates the plan review Fee required is $ _2 c — Fee received is $ a--A* Plan accepted for review. Fee is being returned because of II overpayment Q underpayment. Providing one of the two catagories above is checked, please remit correct total fee in one payment. Indicate plan identification number on remittance. No fee has been remitted. Plans submitted with no fees will be held in abeyance until remittance is received. Indicate plan identification number on remittance. Additional information required. See attached Plb. 100. The permit to start construction will not be issued until 30 days after requested information is received and accepted. Q Plans being returned. See attached Plb. 100. Sincerely, ones A. arg Chief JAS:fjs Seepage trench bottom area planned width �. linear feet depth Seepage bed area planned 1,512' width 24' r linear feet 63' depth 3611 170�" '_pb_ Seepage pit planned outside diameter depth below inlet depth 4. See approved plan for specifications and details. Signatur ocompi ing rm: STATE DIVISION OF HEALTH, PLUMBING SECTION P. 0. Box 309, Madison, Wisconsin 53701 Approved: i Address: 20 W�'ST RFF'T Date: MTTWMjKtE, WI. ZIP 53233 THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIREMENTS AND DOES NOT EXEMPT THE Date: 3/8/76 INSTALLATION FROM CITY, VILLAGE, TOWNSHIP OR COUNTY PERMIT REQUIREMENTS AND SHALL BE VOID IF REVISED WITHOUT THE WRITTEN APPROVAL OF THE DIVISION OF HEALTH. DEPARTMENTAL USE ONLY 4 r� I i �s PlLt. , 60 , 3/ln 'I PROJECT DATA SHEET c , NAK OF BUSINESS Jy pApER BAG MANSJJ 'AMI.I M CO. LOCATION COUNTY TRUNK A NORTH HUDSON ST. CROIX street or highway -e-i-t --tw township county LEGAL DESCRIPTION SE 1/,4, SE 1/4 SEC. 17, T29N, R19W OWNER DURO PAPERBAG MANUFACTURING CO- Mailing address DAVIFrS - OAK ST. LUDIV L KENTUCKY ZIP ARCHITECT OR ENGINEER ROGER W. JOHNSON Address 2120 W._ Clybourn Street Milwaukee, Wisconsin ZIP 53233. PLUMBER UNENOWN Address ZIP 1 . Check appropriate building usage(s) and fill in the information requested opposite each usage listed: Existing building New building X Addition If addition to existing building attach detailed memo for each. ( ) Drive in restaurant Car spaces ° ( )- Restaurant . . . . . . . . . . . . . . . . . . Seating capacity (10 sq. ft./person) ( ) Dining hall Per meal served Toilet waste Yes No ( ) Motel ( ) Hotel ( ) Cottages . . Number of units : 2 persons/unit TOTAL NUMBER O UNITS j unurcnes . . . . . . . . . . . . . . . . . . . . Number of persons Kitchen Yes No ( ) Bar or cocktail lounge . . . . . . Seating capacity (i_0 sq. ft./person) ( ) Nursing or rest home . . . . . . . . Number of beds ( ) Mobile home park Number of units - dependent (camper trailer) - nondependent (mobile home) ( ) Retail store .. . . Number of employees Number of customers T1(5_sq. ft./person) ( ) Service ,stati,on . . . . . . . . . . . . . Number of cars served (daily) ( ) School`­.-'.,',',. . .., , , . , ., ,. ; Number of classrooms Mea 1 s served Yes No Showers provided Yes No (X) Factory or office building , . Number of persons (total all shifts 60 ( ) Apartments . . . . . . . ... ... . . . . . . . Number of bedrooms ( ) Other Specify S­0 7^ / S/00`/JA9E 2. Indicate whether or not the following facilities are connected: Food waste grinder Yes No X Dishwasher Yes No X Automatic clothes washer Yes No X Automatic potato peeler Yes Other . . . (Specify) 2 FIAOR DRAINS No X 3. Fill in the appropriate information for the following as indicated: Septic tank capacity planned 2,000 gal. Percolation test results - ATTACH PERCOLATION TEST AND SOIL BORIN S_t4t ikT SHEET COMPLETE OTHER SIDE