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HomeMy WebLinkAbout030-1094-60-000 III 4 c ° o 0 r 3 c) 3 0 o 0 r» p es3 NC U W ey 4� O O n N o a a) a o Q) '0 o N a� _ N @ L - E a� `7 U N C > c t O r a O Ol c d a) •N C O O C tl a a) N'c0 a) 'O U O)•- h a > M cn a - ) m a �++ N NL NN O c 3 O2 L N E c 4) N c n t a� E cc 3 x O V Y = o Oic') 'O Z U U : z 'O N .0 c U- c o E t ti c 2 _ _ o o U) _ 0 0 o E v a E E "0 (D -- (o a) -a o E 0 <1 o. a v E a) U CO Co CL V a) > Z y i w y Z I I O O z �- d m d d N CO w a m a m C') I- Z i o c is O z Z d' c O N 00 N w W 2 C C O rn a) z E E -o ^�/ O N N CL O Cy V) d y N i N m o 0 •� !, d a O CL C O m O Z (n Z z H z w N c O R E C r0 E N '.. O _ .. p L N i N Vi V! d d O O �y d N - O v a o a a - E E E c� E m n' CL o a- rn 0 _o o 0 � Z O •� a a a 10 m m m y Z a I' w �y r0 r0 0) 0) z 00 00 z "V) O � N � a) c) N U O O 3 w 0 0 -1.1 E O M C0 m =� a N N R 7 a) W U 3 r O 7 o o c E H c U w c O U O L N M N N n O YyO " O ~ H d c 7 N C c U d o c) a) l \ L 4' rh O. C N N E Cu !n E N 8cE8 N N \ v Q O O O O c CO 4 c a) � t; � 00 7 N Cl L' 0 0 O c (D 3 0 'D `) O a) '0 z C • 'a ('7 N U O 0 N O U N O N O p U y O M (n O m Z (n O O N z I- (n O • L:a d .a I. d a a m � ! •� E i C : C j A 0 CL 2 , O in ci O to ci j PUMP CHAMBER '� 1 Manufacturer: / �� 5 Liquid Capacity: �� Pump Model: Pump/Siphon Manufacturer: G �c Pump Size Elevation of inlet: �X.�_ U Bottom of tank elevation: Pump off switch elevation: 2Z Gallons per cycle: / f� Alarm Manufacturer: ; , L LL C T,f C,:i Alarm Switch Type: Number of feet from nearest property line: Front,Side, O Rear,0 Ft.z3�, r Number of feet from well: Number of feet from building: fes (Include distances on plot plan) . SOIL ABSORPTION SYSTEM Bed: Trench: Width: Leng'th:�� Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,O Pt s� Number of feet from well: Number of feet from building: ;23 61 (Include distances on plot plan). S EPAGE PIT ze: Number of pits: Diameter: Liquid the Bottom of seepage pit elevation: Area Built: Has either a drop box O o distribution box O been used on any of the above soil absorbtion sytems? (Check one) . HOLDING TANK Manufacturer: acity: Number of rings used: Elevation of bo om of tank: Elevation of inlet: Num>ber nearest prop y line: Front, &%�deC , Rear, O Ft. mber feet from well: of feet from building: eet from nearest road: Ala Inspector: Dated: IV—10°-E Plumber on job: License Number: ,ZS 3/84:mj Form - STC - 104 _ A AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T N-R W ADDRESS If Tl J3U � 7/ ST. CROIX COUNTY, WISCONSIN b1A1.2S124%4 SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM / z- 57x75- 53 Daic/k- �y cti Cc'd r1 ;=CiL ti INDICATE NORTH ARROW BENCHMARK: Describe the vertical re✓fer nce point used Cii/vc/Te1'� SG/'1D iv��</lc,vr'v.- _ uSE/� l=o:z 7'%.�ENC.tIE,$ ._•.. Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: �Lc— Liquid Capacity: ZOIQ Number of rings used: ! Tank manhole cover elevation: _ Z9 yy Tank Inlet Elevation:, 3 C Tank Outlet Elevation: Number of feet from nearest Road: Front Side Rear, ,� , , O �� feet From nearest property line Front,®Side10 Rear,0 "coo ( feet Number of feet from: well �, building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SrE R1;\11'"I'l. Fij7' NT SAFETY&BUILDINGS E OF INDUSTRY, INSPECTION REPORT FOR LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MA ISM,WI 53707 .�pI Ste NE4,NW%,5�32,T30N-R19W 13 CONVENTIONAL ❑ALTERNATIVE (Ifte Plan l.D.Number: 111 assigned) Town of St. Joseph ❑Holding Tank ❑In-Ground Pressure ❑Mound CTY E LX7 Id NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Dan Score Route 2, Box 271, Hudson, WI 54016 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Donavin Schmitt I3205 St. Croix 92500 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LAB L LOCKING COVER P OV�°ED: PROVIDED: ,,��// ►YES ❑NO DYES L`l,NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: LINE WELL: BUILDING: VENT TO FRESH ALARM: AIR INLET. FEET FROM DYES NO 10YES ONO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO OYES 1:1 NO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL- BUILDING. VAER NOT RESH (DIFFERENCE BETWEEN FEET FROM LwE PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH. JNO�UF DISTR.PIPE SPAC N?_. COVER INSIDE CIA. SPITS LIQBED/TRENCH + TRNCT / 1 M RIAL: PIT DEPTH DIMENSIONS S 7 5 /)^ (�Gw RAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI R. NUMBER OF PROPERTY WELL: BUILD►NG. V NT TO FRESH BELOW PIPES. ABOVE COVER: ELEV.INLET ELEV.END: PIPES. FEET FROM LINE: AIR INLET. NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ONO SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES Is ❑ 'ES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER: EDGES. OYES 1:1 NO OYES ONO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.: ELEV.: DIA.: ELEV.: PIPES DIAJ ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ❑NO DYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: 1. q�y DYES El NO ❑YES 1:1 NO INEAPAGT WL 1 qM f Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE. DILHR SBD 6710(R.01/82) 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 if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber'requires a Sanitary Permit Transfer/Renewal Form (SBD 6399Y to be submitted to the county prior to installation; 5. Private sewagesystems must-be-properly maintained': The septic tank(s) should be pumped by a licensed pumper whenever necessary; us6ally 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; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;_ III. Purpose of application: Check only one in 41. 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; Vl. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill'in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. V Complete plans and specifications not smaller than 8Y2 x 11 inches must be submitted to the county. The plans must include the following, A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump"m`odeT'and,,pump manufacturer; D) cross section.of the soil absorption system if required by the county; E) soil test data on a 115 form. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over-2.years of steady negotiation and public debate.The groundwater bill Ground ailef included the creation of surcharges (fees) for a number of regulated practices which Wisco E17f can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re c Sure. e is used in your building is returned to the groundwater through your soil absorption u 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 funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) SANITARY PERMIT APPLICATION COUNTY DILHR In accord with ILHR 83.05,Wis.Adm.Code A� STATE SANITARY PERMIT# 9d w —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 I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES LZIJ� NO PROPERTY OWNER PROPERTY LOCATION C I e'/4 /4, S3,2 T N, R E (or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 13ir a CITY,STATE ZIP CODE PHONE NU`MSB �'/ VILLAGE: _ NEAREST ROAD, OR LANDMARK II. TYPE OF BUILDING OR USE SERVED: �J - 1W, 030 -169q- Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.X Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. X Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d.❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. %See a e Trench c. ❑seepage Pit 2, PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch REQUIRED(Square Feet): PROPOSED(Square Feet): ap ?S"./2 750 $10 6G 7a -A2Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin structed Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank Od I���1�-5 ❑ Lift Pump Tank/Siphon Chamber i ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumb 's Signature:(No Stamps PRSW No. Business Phone Number: Plumber's Address(Street,City,State,Zip Code): V Name of Designer: RT.2 all/ VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# ^ SfE,6L r CST's ADDRESS(Street,City,State,Zip Code) Phone Number: !1 ElL Ri C"y dN,0 i 5 �C IX. COUNTY/DEPARTMENT USE ONLY. ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Su harge Fee o Approved ❑ OdversGiven ermial Q� D6 1I_1S �p 7 j� `m Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber i 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 Location of Property Section T .gyp N-R_� Township j f -T S F Mailing Address 02 - ',e e #/ao.3 Address of Site e `Subdivision Name Lot Number Xa— ;Previous Owner of Property ',I Total Size of Parcel -s U a C yes Date Parcel was Created Are all corners and lot lines identifiable? .`/ Yes No Is this property being developed for resale (spec house) ? Yes ✓ No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION 1 (We) eentiby that att statements on this bonm ane tl(.ue to the best ob my (oun) hnowtedge; that 1 (we) am (site) the owneA(.$) o6 the pno pen ty de 6 c i.b ed in this .inbonmati-on boAm, by vi tue ob a waAAanty deed %econded in the 066.ice ob the County Registen ob Deeds as Document No. ; and that I (We) pnesentty own the pnopos ed site bon the sewage dU.6 po.s b y6 em (on I (we) have obtained an easement, to nun with the above deg ni.bed pnopenty, bon the constAuction ob said .system, and the .same has been duty %eco&ded in the 046.iee ob the County Reg.csten ob Deeds, as Doewnent No. ) . IGNA OIL OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED lee 4k Pro �{ yy���y ♦S S ,: ` $vb, At ; k 3 �. .i..t. #ga'yr n "� 4i3rY: ♦ �,� � 3 ,6.�" a. H z o, ' H STC - 105 a H SEPTIC TANK MAINTENANCE AGREEMENT c St . Croix County z d a OWNER BUYER L A' ROUTE/BOX NUMBER R4-a Bx. al ► Fire Number 1003 .CITY/STATE w • • ZIP 5-40 l PROPERTY LOCATION:/1/ , ' , Section 3.2- , TAN, R /9 , T of St . Croix County, hh/� Subdivision _717/­7_717/­7 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 pdt 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. Ho E I/WE, the undersigned, have read the above requirements and agree 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 Office within 30 days of the three year expiration date. /� SIGNED o' Lc� DATE ' 9- St . Croix County Zoning Office P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address . INSTRUCTIONS FOR COMPLETING FORM 115 - SR[) - 6395 � Y To be a complete and accurate soil test,your report must inclucle: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. 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; 6. PLEASE use 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 sheet:may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as re<luired. 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 st - Stone (over 10") BR - Bedrock cob .__ Cobble (3- 10") SS - Sandstone gr -- gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater es - Coarse Sand Perc - Percolation Rate med s - Medium Sand W -- well fs - Fine Sand Bldg -- Building Is Loamy Sand - Greater Than sl -- Sandy Loam Less Than �l - Loam Bn _. ,Brown sil - Silt Loam BI - Black si - Silt Gy - Gray cl .-. Clay Loam Y - Yellow scl - Sandy Clay Loam R Red si(,,l - Silty Clay Loam mot Mottles sc Sandy Clay w/ - Lvith sic . Silty Clay fff fekv, fine,faint Ix c Clay ce common, coarse Pt -- Prat mm - Many, medium m Muck d - distinct t) - prominent HWL - High water level, Six caeneral soil textures surface water for liquid waste disposal BM - Bench Mark VRP Vertical Reference Point TO THE OWNER: This soil test i eport is the first step in securing a sanitary permit. The county or the Department may rt.quest vorifi;ation of this soil test in the field prior to permit issuance. A comt�lete set of plans for the privatsx sewage system and a permit application mess, lte- suhmn ttcgi 10 the appropriate local authority in order to Obtain a permit. The sanitary permit must: be oh'taine_I antj (jilts to'hu start Of any C011I trGCtio ll. r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN RELAX IONS (H63.090)&Chapter 145.045) LOCATION: SECTION: TOWN'3HIP/NNXNXD@V0M LOT NO.:BLK.NO.: SUBDIVISION NAME: NE � W��N 32 /T3011/1119 (or)W St. Jose h n/a n/a n/a COUNTY: OWNER'S RU0MSLT0UWE: MAILING ADDRESS: St. Croix Dan Score R.R.#2 Box 271 Hudson Wi. 54016 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 n/a ❑New=gReplace 3y27-87 n/a RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) ®S ❑U ❑S �U ©S ❑U ❑S E U ❑S U trench 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: class 2 Floodplain,indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 42 COE BORING , DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTHXK ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 1 17.50 98.70 none >7.50 .75bl.1. 2.00bn.sil. .50bn.s.l. 4.25 bn.c.s.&g. B- 2 17.25 98.62 none >7.25 .67 bl.l. .83bn.sil. .83bn.s.1. 4.92bn.c.s.&g. B- 3 17.15 95.62 none >7.15 .50bl.1. .83bn.sil. 5.83bn.c.s.&g. B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PERI PER INCH P- P- P- P-_ P see eslgn rate 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. upper trench =95.12 SYSTEM ELEVATION lower trench 92.12 1 _ b 14> 4� 1 �VI'� Is F E E T . _ A_-j" - tHz ��o� g._ r �r... �_.__� _ ` ( ' to U,� "�u� •��� �,3,1 t i s 3 x i Ak ny s' e _.y ?. I fl I _ _ ( 3 .fit I,the undersigned, hereby certify that the soil tests repor orm 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: Gary L. Steel 3-27-87 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 988 N. Shore Dr. New Richmond Wi. 54017 2298 CST SIGNATU E. DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — r' AV• r t' c r r Mr l Toss _ C _ fle G c,� • 10 #> CPC J /Plo �.� car a c Cal . „ r _ _ Sri ' LAS ) jovo 'r�� AIM 1 C 7 Y. '0 _ Wisconsin Departomt of Health and Social Services ` Pb;#67 3/70 Division of Health SEPTIC TANK PERMIT APPLICATION TYPE or USE BLACK INK A. OWNER OF PROPERTY Name Address (Street, City, Zip Code) Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED J COUNTY Check CITY VILLAGE LEGAL DESCRIPTION ]xU Z? �( TOWNSHIP /f C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? X YES NO y ,/ PERMIT NUMBER D.. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALSs Prefab Concrete Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLEDs `"?I C--/ E. TYPE OF OCCUPANCY Check Ones One or Two Family Residence Commercial Industrial Other Specify Number of Persons to be Accommodated Number of Bedrooms F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer X YES NO Dishwasher YES x_ NO Automatic Potato Peeler YES Y' NO Other (Specify) G. MASTER PLUMBER MAKING INSTALLATI Names e ` a,�c' ,9 Addresss i t "�/i e/'/(.C!'1' �/y✓'License Numbers HP Signature of Applicant i HP RSW /,_ /•. Address: �• (Too' be Completed by Issuing Agent) '/ Date of Application p Fee Paid = Permit Issued (da*_s) U' 4 �/ Permit Number `':��: Agent (Name) Tors t= eh Town, Village, City, County, etc. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward appiication, the fee of $1.00 for each septic tanK and the third copy of the permit (canary) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below FOR DEPARTMEXT USE ONLY Y. DATE RECEIVED — I�'�II ACCEPTED. BY RETURNED Ll (Initials) �1 (Date) See Corr s. FEE RECEIVED VALID. No. �vo PERMIT NO. as or No REVIEWED BY APPROVED VATS (Initials) Yes or No COMPLETE OTHER SIDE SEPTIC ?ANK PERMIT 110. REPORT ON SOIL PERCOLATION ? EST . AND SOIL BORINGS TO DIVISION OF HEALTH • PLU KBM SECndu P.O.Box 309, Madison, Wis. 53701 r Pursuant to H 62.20, Wis. Administrative Code P E R C O L A T I O N TEST Test Depth Character of Soil Hours Water Test Time min or Level Inches Minutes Number Inches Thickness in Inches Sines Hole in Hole Interval Second to Next to Last To Fall lst Wetted Overni&ht in Minutes Last Period Last Period Period OnerInch Example P • 0 36" Top Soil 10", Cla 26" 25 Yes or No 30 142 112 1 2 60 -IC -�7 - r 41 16 /J 7 r RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S 0 I L B O R I N G S - Minimum 3611 Below Pro osed Abso Lion S stew Boring Total.Depth Depth to Ground Water Depth to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches Example B - 0 72" 72" �/ Black ToE Soil 12"t CYZ i8l's Sand 181 G.avol 24" RECORD DATA FROM MINIMUM OF 3 BORE HOLES PE OF OCCUPANCYt RESIDENCES Humber of Bedrooms OTHERS (Specify) Number of Pe.rsons- POOD WASTE GRINDERS Yes No Dishwashers Yes No %_Automatic !Clothes Washers Yes +No 'FFWENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT Tile Site Z/ No.Lin.Feet t4--v Trench Width Depth d umber of Lines / Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pits Inside Diameter !' Liquid Depth I# the undersigned, hereby eertily that the percolation tests reported on this form were made by me or under my super- vision in accord with the prooe res nd method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data re *rded.and loca ion 0 tea holes are correct to the best of my knowledge and belief. NAM ,,. 'IMi TITLE %lype or Print)JJ REGISTRATION NO / MASTER PLUMBER LICENSE NO. U ADDRESS 4-Z� �C �r DATE c�5 SIGNATURE ' 641 pl� V22 zq 30 30. 04L Pal ir kz ,Vv 2 3 -2 -r7C © o — -76o L4 vv th, i M. i APPLICATION FOR SANITARY PE��HIT for INSTALLATION OF A 'OU= TANK (Sec. 144.03, kris. Stats.) 1 i A. UINER CF PICHRTY _ - Nam '..Address (Stree , , ,r ip Code) B. LOC�TICN CF PKPE'tTY :rHF3. SEP TIC T ANK IS TC B"-1 INSTALLED � i 7 Check 1. City Mail dress - County one: 2. llage 3. jTo, wn ' C. INSTALL%:Z Give License`n h ld: Wisconsin Restricted Licensed Sewer Plumber Services-g Name // Address A. D. SPTIFIC-',TICNS CF S7PTIC TANK Size in gallons: (check one) 1.1,000 Gal. 5.. . _ 4,000 Gal. 2. 1,500 Gal. 6. _ 5,000 Gal. 3. 2,000 Gal. 7. Ir" over 5,000 gal., give capacity. --3,000 Gal. Materials: 1._4Prefab concrete 2. Poured concrete 3. Steel E. TYPJfSin;!le CCCUP.:ANCY 1. Family residence 3. Commercial establishment 2. M.;itiple family residence 4. Industrial establishment F. APPRCXDLITE NUMB:,�3 OF P,ZSONS 8,7-WED DAILY G. P�'3CC.-LATICN TEST T/�ADE 1. Yes 2. No Date By whom Z (To be completed by County Clerk) / Date a,plication is filed and fee paid Permit issued (date) /;' /� r Permit Rimqber �J County -j {. k Clerk