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HomeMy WebLinkAbout020-1161-80-000 y O h ti Q t a 4 Ncc ~O ! y m N N n ) O� aci co Jam M O >,'ii et wC- 'es -a m=.2-@ c—6 c Vi �. cm-0 CL yE �. c O N c N d 7 m E E o a> LL o o aw 3 E m E v E o c w I O) W U O (� C O.M N H U) d m U Co M ?? I C Z C E > ov a M M �w N O O O Cj CL w III y y -O /d O O O Lo •IV d L_ > N R f6 N O Z fo Z O IZ O LO O O � N � a L t Lb Ti u - °�' w y c �i > c O G a a o co 0 o U) v> ; o LL N '' = o o O a •N o � aaa ►� a m c 00 o N tv! M 0 0 •_ -O O O 00 co co L m c CL �,w (D o N b+ O C C O D O O M 0 Q 0 0 3 (D c C 5 a 0 0 0 o r N N N N V O c0 ~ > C N N C V O O _) C C O y N n N Z Z C y 0 0 .= H N M O O c0 O y O O O tl • ))) O N 2 O O Z V d € a.#t a L: a • � Qy u ��l y I c 3 �1 A Ciao !, 0U) U 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: I Number of feet from building: (Include distances on plot plan). Shit,: 1.00 HCADtR SOIL ABSORPTION S STEM '000 Eloo 93. 38 ' 93.3 101-00 9150 Bed: Trench: yy g•SV Width: I Length: cat Number of Lines:—D,- Area Built:_—Ul Fill depth to top of pipe: i Number of feet from nearest property line: Front, O Side, (�Rear,o Pt .� Number of feet from well: 0 x/11 yt� 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, 0 Ft. ,____._ Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: w / 4'Y License Number:� � 7�p 3/84:mj v Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER VeRc.j 3001 j TOWNSHIP HV j SU TJ SEC. T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 s y5' a o 006 ' 5a !d' GtAH!Out, S � I 1 � INDICATE NORTH ARROW 1 I i 1 BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: loo- Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: 1000 T Number of rings used: — Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,O Rear, Q ffi_J_tiL feet - From nearest property line Front 10 Side,©Rear,O _ feet Number of feet from: well ��_, building: 131 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: ` Liquid Capacity: n 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, Q Side, O Rear,0 Ft. Number of feet from well: `�+ Number of feet from building: (Include distances on plot plan). 5;1�,� .� i.<1( Cf�1?,z1z 93-SS'- 73—r1!)' SOIL ABSORPTION SYSTEM ' OUO ►e? 93• ' 9�•'r . J 101 -00 Bed: Trench: Width: � oC Length: Number of Lines: _ Area Built: _ Fill depth to top of pipe: Number of feet from nearest property line: Front, 0 Side, (aRear,0 Ft . )of Number of feet from well: 4 �N Number of feet from building: 155' (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, 0Ft. Number of feet from well: Number of feet from building: Number of .feet from nearest road: Alarm Manufacturer: . Inspector: r Dated: Plumber on -job: � (PI License Number: I �D 3/84:mj DEPARTMEN i OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS B P.O.B PRIVATE SEWAGE SYSTEMS DIVISION OX 7969 MADISON,WI 53707 BUREAU OF PLUMBING SE;r;="ft'� , S23,T29N—R19W ]CONVENTIONAL ALTERN TIVE State Plan 1.D.Number: Town of Hudson nt assigned) ❑Holding Tank ❑ In-Ground Pressure Mound Lct 26 Fox Valley NAP.".E OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Vern Jones 5980 W. 176th St. Box 446 Farmington, MI 55024 BENCH MARK(Permanent reference point)OF C IBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.. CST REF.PT.ELEV.. Name of Plumber V MP/MP W N .. County: Sanitary Permit Number Richard Hopkins 1059 St. Croix 96047 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED, PROVIDED. YES LINO ❑YES CANO BEDDING: VENT DIA.: VENT MAT L.: HIGH WATER NUMBER OF 'ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH ALARM. LINE AIR INLET. ❑YES NO C 1 ❑YES 7 NO NEAREST �' V V DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY MV DEI_. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED DYES ONO ❑YES ONO DYES ONO GALLONS PER CYCLE: PUMP N C TROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) OYES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire construction shall cease until FORGE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: e�f �yC WIDTH: LENGTH. NO OF DISTR.PIPE SPACING. COVER [N11 E DIA. #PITS: LIQUID TRENCHES MTRIAL: DEPTH. tIMENSINS 1 2 5 2 _ PIT GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV END PIPES FEET FROM LINE, AIRET: `` y2 3. SJ 9.x.39 2 7 2 2 NEAREST 12 0 ► gS j MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER ITEXTURE PERMANENT MARKERS JOBSERVATION WELLS 1:1 YES F-1 NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCHiBED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER EDGES. ❑YES ❑NO EYES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: ' WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: 3EbITRENCN TRENCHES: tiENfttNNS ' `, MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: tL ^-TV[A AI ELEV.: ELEV: DIA_. ELEV.' PIPES DIA.: £�ISTI ?1 F{tt .. � � HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS Inum SE la CIF( PROPERTY WELL:E'i FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST CA / v� Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710(R.01/82) ~/r Zoning Administrator INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed it there is a change in your building plans, system Iccation, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to instaljation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact-your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; 11. Type of building or use served: If public is checked, ndicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; Ill. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, tification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8%z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building servec; B) horizontal and vertical elevation reference-points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a.115 form. ------------------------------------------------------=-------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public de'Date. The groundwater bill Ground _ ter included the creation of surcharges (fees) for a number of regulated practices which Wisco in,S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried IStf@ is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These fun:ls are used for monitoring ground- t g-ourndwater contamination ins estigati.ans and est _blip hmerit of standards. a roll ndviat- s vicsrt�: protecting. Sat?-6398 ;8.0186) II DILHR SANITARY PERMIT APPLICATION °O Y In accord with ILHR 83.05,Wis.Adm.Code , °�....s..o. STAT SANITARY PERMIT (, 0q —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION gyp(' 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES Z%I NO PROPERTY WNER PROPERTY LOCATION K) I A/QS 5-E. '/,,S %, S ;3 T��, N, R E (or)W PROPERTY OWNER'S MAILING DDR�Sj , f LOT NU BER BLOCK NUMBER SUB I ISION NAwlf I I Y,STAtiE iW\ l(¢ ZIP CODE PHONE Nv7UMBER CITY NE R T R D,\LV� OR LA MARK ❑ VILLAGE : SON i�� A II. TYPE OF Bi LDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family_ OR El Public(Specify): 111. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. LX New b.El Replacement c. El Replacement of d.El Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) 1. a. %Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. Kseepage Bed b. ❑seepage Trench c. ❑See age Pit 2. PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPQqF.Q u re Fee): cc 3 ' J Feet Private ❑Joint El Public VI. TANK CAPACITY Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank d Lift Pump Tank/Siphon Chamber 1 ❑ ❑ 1 Li VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plum is Signature:(No tamps) MP/MPRSW No.: Business Phone Number:J_�JDk, R N aA IC I �J_f I-os i fox Plu b is ress treet,C y, te,Zip od N pf De igner: C _N L VIII. SOIL TEST INFORMATION Cert i of Soil Tester(CST)Name CST## &P &j CST's S(SYXIIA State Zip Code) Phone Number: .-A S �, 39 4.- 0 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial __11 r) urc1ha�r-g^e Fee Adverse Determination /Ov' v� /3 47 1 X. COMMENTS/REASONS FOR DISAPPROVAL: I �Cch ('vdl b �vk,�..s �, fJe I�sc3� SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber v 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 �� �y�' of Location of Property it /' Section Q� , T N-R W Township UJZj Z Mailing Address �Z 2 ZL�L___. �'i- Address of Site , Subdivision Name �p�j O LG � T •ice X � ,�¢ y Lot Number Previous Owner of Property Total Size of Parcel �• 5J Date Parcel Was Created Are all corners and lot lines identifiable? Yes 15( No j Is this property being developed for resale , (spec house) ? Yes No Volume �� and Page Number 5 ? as recorded with ,the Register of Deeds. t 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 1 (we) centi.6 y that a t .6 tateme.nts on this 6onm aice ticue to the but o6 my (oun) knowledge; that I (we) am (cute) the owneh(s) 06 the no ent y deAc/ i.bed in .this p p in6oAmation 6onm, by viAtue o6 a waA.anty deed hecanded in the 066ice o6 the County Reg.isxeA o6 Deeds as Document No. -3?0 i/ Z,. ; and that I (We) ptesentfy own the pupos ed 6ite 6oh the d ewage d"po.6at s y,6te-m (on I (we) have obtained an eas ement, to nun with the above des cni.bed pnopeh ty, bon the consticuc ti.on o6 aaid system, and the dame has been duty kecokded in the O66ice o6 the County Reg-i,6teA o6 Deeds, ad Document No. SIGNATURE OIL OWNER; SIGNATURE OF CO-OWNER I ( F APPLICABLE .,21 DA SIGNED DATE SIGNNED