HomeMy WebLinkAbout036-1094-10-000 4 o
a O � 0 6
`' o)
I �
H a III C O
C •: A
to
CD
CL o a
N Q N t N
h N i)i U)f6 r
~ y0)
D 00
a) C O
O-N
? r-
C>
O O co w O Z
'`00 C C a)
II N C.O •C
30 V
y
Y C O L
.� 0 0'0 C
y U N O'm
0 c
c
a Z > N o ' �
p Z N d a) O.
I'I G y N C
U. c 7 (6 — O
LL C (aL LL •� N Om
3 Lr
o rn•� L
v °od 0) v
co a)
ii E Q
m
CL
(1
£ E
n Z ! ;; O r O
Z a) N d d
M � ZI' am a m
O Z � c c
N � �
a0i Z d ° c 2
cm
c
c
N N a)
N j C
7 d N
CD N N O a)
•�� d O) L d (n t
III'. O a) Q O O (L) Q O
O Z (n Z Z co Z
NII I
CL II o U rl c U
(D a)o N N Ln p a m `y
Z .- > H Fes- Fes- O H Ff n- FfA O
s
3000 as X000 a
•►A4 ;II � aaa � aaa
a g j E E
— Z 0 E O
N
O O to
ca 'O O O .�
Ca C m W rn a)
o O
N (D
Q Z Cn = 'p 41 Q } to N
I,,' O 7 LO 7 .�
O) I�yA C
o
IV •F+ O O 'O O E (O O
0 o 3 m y �' .� _m a°i c c a C> o
prn ~ Q c m m Q aci a c co
b Z O a)N
N O — N ap a> N Z, C_ aJ
•►xV.1 M (O 0 N co O 0 N a) pOj O 0 O O O V
O M U) m 0 Z 01 2 Z CO O O Z
r� :w
Ag
V cc E
E .�
E E
a a
CL 'coi � a �' a� CL
• m m c y c
c
v 'c c a.2 0
—1 A V aL 2 O N V O N V
# o
�
) 0 `
0
m§ c%§»k t£ Rm
2%%
CL 0)
:
2 (
/
% §/
§ m
E �-
■ �6 °k
7) § >
2 & 0
� . ��kk �
Cc
;_ 0
2 .
% z \ � 2 §
/ 2 � e §m » ■
- � 0 a CL
� c co
k
:E CL
m } z a m
�
B z +
2 7 )
. [ \ 2 0)
9 ƒ
Q
0 co )
t
» °
Z . �
cc
' 2 )
� � ~ CL
) \ / / §
B B §
•� £ / a a a
i 4j
J j v ) 7 k
( z §
co 2
2
� ƒ % k # ) f �
� 4
° 0
\ k \ \ \ c ) \
& f \ CO a
■ ) k q 0 ] -
- CD \ ) \ m k o 2 $ f k
2
:w
2 � IL
CL
� k CL
/ J a 2 : o $ J
• f y
PUMP CHAMBER /
Manufacturer: y,,,�,.,�( �;�� r aN: c Liquid Capacity:
ti
Pump Model: bj;A 5jL Pump/Siphon Manufacturer: Pump Size ,
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle: l46
Alarm Manufacturer: _' �1� Alarm Switch Type: f, A } 4� /
Number of feet from nearest property line: Front, O Side, O Rear,( Ft. 1Gh
Number of feet from well: C�'
Number of feet from building:
g�
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built
ii
Fill depth to top of pipe: �
Number of feet from nearest property line: Front, O Side, Rear,O Ft .
Number of feet from well:
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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
r� Inspector:
Dated: �l Plumber on job:
fi License Number:
3/84:mj
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER �� �, f1h� TOWNSHIP J ) SEC. *- " T jN-R1�W
ADDRESS ST. CROIX COUNTY, WISCONSIN
a
J..
SUBDIVISION ) LOT LOT SIZE
PLAN VIEW j
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Otis/'
y /
r
�nn
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: %/J�,�� Proposed slope at site:
SEPTIC TANK: Manufacturer: /)
/�;,1��,�'[',�r.,,u �iquid Capacity:
Number of rings used: �_ Tank manhole cover elevation:
Tank Inlet Elevation: ET Tank Outlet Elevation: $3 S
Number of feet from nearest Road: Front,O Side,Rear, O 71-- �560 feet
From nearest- property line Front,O Side,O Rear,O p L feet
Number of feet from: well � , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIMATE SEWAGE SYSTEMS DIVISION
P.0_,5OX-3969 BUREAU OF PLUMBING
MADISON,W) 53707
NW'-4,, NW4, S36,T31N—R17W C7CONVENTIONAL E]ALTERNATIVE ISiale Plan I.D.Number:
It assigned)
Town of Stanton ❑Holding Tank ❑ In-Ground Pressure ❑Mound
HWY 64
NAME OF PERMIT HOLDER: DDRESS OF PERMIT HOLDER: INSPECTION DATE:
A
Allan Benson Route 3 New Richmond WI 5401
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:
Calvin Powers Jr. 1563 St Croix 9 082
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV. IWARNINGLAB EL LOCKING COVER
PROVIDED: PROVIDED:
YO uJ RAD 1), 5,17 (0)3 b YES F-1 NO DYES NO
BEDDING: VENT DIA.. VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING:IVENT/TO FRESH
C1 ALARM FEET FROM LINE AIR INLET
❑YES O ❑YES NO NEAREST
DOSING CHAMBER:
M OF ACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
3.J�� DYE O �J�d YES ❑NO YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: SE.R OF =PROPERTY WELL. BUI DING. VENT TO FRESH
(DIFFERENCE BETWEEN /� FE FROM LINE l �U AIR INLET
PUMP ON AND OFF) / YES ❑NO NEAREST ✓/�/ 7
SOIL ABSORPTION SYSTEM.Check the soil moisture at ig depth of plowing LENGTH JDIAMFTER MATERIAL AND MARK MG
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:
QED/TRENIuN WIDTH LENGTH NO OF DISTR PIPE SPACING COVER NSIDE CIA #PITS JILIQUID
�•� TRENCHES: / i MATERIAL: PIT DEPTH:
`t1l1Mtk$IONS f< 1/
GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO. STR NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END-. PIPES LINE n Al R I ET
9.�,� s �� A- 2 2 3 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 IPERMANEN i MARKERS OBSERVATION WELLS
1:1 YES ❑NO 1:1 YES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED :71 TOPSOIL. SODDED SEEDED. MULCHED.
CENTER. EDGES:
❑YES ❑NO 1:1 YES 1:1 NO 1-1 YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
B�D�RENOH WIDTH. LENGTH. TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTHA BOVE COVER.
:,WMENS ONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE M MATERIAL. NO.DISTR. JDISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
ELEV.. ELEV.. CIA.. ELEV: PIPES: DIA..
ELEVATION AND
D15TR BllTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
fNFORMATION I PLANS
❑YES NO El YES F-1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
1 ❑YES NO 1:1 YES El NO NEAREST
g,� I i i, a
Sketch System on 1 y ,_ ' Retain i ounty file for audit.
Reverse Side. RE: ITTLE
Zoning Admin
DILHR SBD 6710(R.01/82) t ,a
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION t
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
IL Type of building or use served: If public is checked, indicate '`ype of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8%2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
------------------------------------------------------------—----------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill GroundtQa
included the creation of surchai ges (lees) for a number of regulated practices which Wisco irt`S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reaSUre'
is used in your building is returned t 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 funds are used for monitoring ground- t
u, ter, groundwaier contamination investigations and establishment of standards G3roundwate r,
it's worth protecting.
'DD-6398 iR,OM6I
SANITARY PERMIT APPLICATION COUNTY
� DILHR In'accord with ILHR 83.05,Wis.Adm.Code x
STATE SANITARY PERMIT#
, r
—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. [FORTARIANCE ON �{�
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. ❑YES E NO
PROPE TY WNER PROPERTY LOCATION /
'/ '/4, S�(� N, R E (or)®
PR E OWNER'S MAILING ADDRESS LOT N�I/IUIBER BLOCK,NUMBER SUBDIVISIO NAME
CIT ,STATW ZIP CODE PHONE NUMBER CITY NEA EST ROAD,L KE OR LANDMARK
VILLAGE
M TOWN OF: ��kIIAAI
II. TYPE OF BUILDING OR USE SERVED:
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.VAn New b.g Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System E 'stin System
Sanitary Permit was previously issued. Permit## Date Issued
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. ®seepage Bed b. ❑seepage Trench c. ❑seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
Feet ®Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App
Tanks Tanks
Septic Tank or Hold ina Tank 42Z I —
Lift Pump Tank/Siphon Chamber ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plu er's Name(P int. 7P[lber'sSign ture. No St ps) MP/MPRSW No.: Business Phone Number:
.3 l3
Plumb 's Address)&reet,City ate,Zip Code): Name of Designer
VIII. SOIL TEST INFORMATION
Cert''ed oil Tester ST)Name CST#
i
C 's DDRESS treet,Cit rate,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ proved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
�1Approved Given Initial urcharge Fee p (j
Adverse Determination
X. C MMENTS/REASONS FOR DISAPPROVAL: _
/ A
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INSTRUCTIONS FOR OMPLETING FORM)15- SBD - 6395 .
To be a complete and accurate sail test,your report mast 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 this a new or replacement system;
B. 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 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 sme your benchmark and vertical elevation reference paint are clearly shown,and at permanent;
0. Cornplete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp-
tion if appropriate;
10, if tl;e information (Such as flood plain,elevation)does not apply, place N.A. in the appropriate; box;
1 1. Sign the form and place your current address and your certification number;
12, Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN :30 DAYS OF COMPLETION.
ABBREVIATIONS FOR ERTIFIED SOIL TESTERS
Sail Separates and Textures Other Symbols
st — Stone (over 10") BR Bedrock
yob Cobble (3- 10") SS — Sandstone
cgr — Gravel (under 3") LS - Limestone
s — Sand [-IGV;r — High G;oundwater
cs .- Coarse Sand Pere° — Percolation Rate
rne;'r? q --- Medium Sand Vv .—. VV re l'
f•; __ Fine,Sand Bldg Building
rA � Sand
Fa — L,r�rny ,� -- Greater Than
sl
Sandy Loarn r' __ Less That)
Loam Bn - Brov,n
s€1 Silt Loa€n EI Black
s - Silt C3y Gray
c! Clay Lo aain 'fellow
scl ._ Sandy Clay Loam P __ Iced
siu-,,l — Silty Clay Loarn mot Mottles
sc Sai,dy Clay wr' — vvittr
sic Silty Clay f f --- fe v,fine, faint
Clay
f cos _ cornmon,ex�aare
pt peat tore; Many, nle'diurn
raa — C;stsck of -- distinct
p — promineni
H W L — High vaater level,
Six general soil textures surface water
for liquid waste disposal BM Bench Mark
VPP Vertical Preference Point
TO THE OWNER:
n test r.epor" is the first step it) securivig a sanitary permit.The county orthe Department 1rnay rTCJUest
vrl' iticafion of this soil 'rest i,a Mae; field prior to permit issuance, A complete set of }Mans for the private
'.'e2 syslern and a per-rnil applicati,an roust lsta suliraaitted to the aataprop=dale local oat:€acuity in order to
s v)crrnit. The sae =-Cary p el nt-in p'a'st oe ob„aii'Ff;d and pos'led pl for to the start of any construction,
UILDINGS
IN*STRiK' DIVISION
LA, AND PERCOLATION TESTS (115) MADISON WI 53707
A,
HUMAN RELATIONS
(H63.0911)& Chapter 145.045)
L CATION: ) SECTION:T u/R/ W TOWNSHIP/MUNICIPALITY: LOT f�OIBLK. O.: SUBDIVI ON NAME:
C UNTY: OWNS BUYER'S NAME: MAI LING ADDRESS /
OZZ
a
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL - ESCRIPTION: [A Replace
FIL DES RIPTIONS: PERCOLATION TESTS:
Residence ,� ❑New I,Z`JReplace ��•,1
RATING:S=Site suitable for system U=Site unsuitable for system
ros ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN- ILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
❑U ®S ❑u ES EA ❑SF ❑S [�JU
If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the
under s.H63.09151(bl,indicate: Jt /� 7 Floodplain,indicate Floodplain elevation: �/Al A
PROFILE DESCRIPTIONS
£o fr
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH 1W, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABB.RV.ON/BACK.)
i
- /-
B-
f 7
c ) S
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAPER INCH ES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIO 1 PER P R
P- 3 3
i
P-_
P-
P- _
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings an the direction and percent
of land slope. '0
SYSTEM ELEVATION
I
AIT
Yk f _
_t
ri
i
t
S
E _
frj
I I
s
E
�.._..Y. -
�
I,the undersigned, hereby certify that the soil tests re orfed 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 loicat of the tests are correct to the best of my knowledge and belief.
for
NAM rint : TESTS WERE COMPLETED ON:
AD /IS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
C IG T E:
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
`' -
��� PAGE OF
i
,f PUMP CHAMBER CROSS SECTION AND . SPECIFICATIONS
NCB---1 �,�/--`•/s'-ss:
VENT GAP
WEATHER PROOF
1' C.I. VENT PIPE APPROVED LOCKING
� 25' FROM DOOR, JUNCTION BOX
MANHOLE COVER
WINDOW OR FRESH 12°MIU.
AIR INTAKE
GRACE
4"MIN.
CONDUIT — �
LNI_.F PROVIDE I -----
AIRTIGHT SEAL
I I
APPROVED JOINT A ( I) I APPROVED JOINTS
W/C.T. PIPE. r I III W/C.I. PIPE
CXTENOIKIC• 3' ( 111 ALARM EXTENDING 3'
ONTO 54t.I0 Sr'!;, B I I ONTO SOLID SOIL
I
I
ow
c I I
PUMP—� --�
� OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED GkJLy IF TANK MANUFACTURER HAS SUCH APPROVAL
5PECIFICATI0 KJS
SEPTIC AND
,DOSE TANKS MANUFACTURER: pn4_)A� < < 1�r�>�� c�r=�'� IJUMBER OF DOSES: � PER DAy
TANK SIZE : �>~X!D / GAL_LOIJS DOSE VOLUME / f
ALARM MANUFACTURER: �: ,_ %/r":'nf% �fci•_: %Ai INCLUDING BACKFLOW: /• GALLONS
MODEL NUMBER:_ '44,/ CAPACITIES: A= IAICHESOR GALLONS
SWITCH TYPE: ~ C r'/_ B=— 3 INCHES OR _Zn GALLOKIS
PUMP MANUFACTURER: C=INCHES OR �� GALLONS
MODEL NUMBER: �l1�L7 311L D= _INCHES OR GALLONS
SWITCH TYPE: NOTE: PUMP AND ALARM ARE TO BE
PUMP DISCHA.R`E RATE GpM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE Bt tU PUMP OFF AND DISTRIBUTION PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . , . . 2.5 FEET
♦ FEtT OF FORCE MAIN X FYofT.FRICTION FACTOR.. FEET
I = TONAL DYNAMIC HEAD a"_ FEET
INTERNAL. DIMENSI OF TANK: LENGTH —�;WIDTH -;LIQUID DEPTH _
StGK)E0: LICENSE MUMbER: ,/� DATE: I( l;z-
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house") , then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property ff'//nZ �� �f �d
Location of Property ) �4 �4, Section , !> T N - R �� W
Township
Mailing Address /-,:5
N
Subdivision Name
Lot Number
Previous Owner of Property Q cl",dzks.ZQ2z
Total Size of Parcel S�
Date Parcel was Created ,off;r-- � ZZL
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes x No
Volume and Page Number ,2 7 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
�.
�Warra�ntyeed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) eeAt%4y that aU statement on this bonm aAe true to the best o4 my (our.)
knowledge; that I (we) am (are) the e�eabove r.( e prop y de cAibed in .th"
in4onmati.on 4onm, by v�tue oA a wy deed ne onded in"the OA4ice o6 the
County RegisteA oK Deeds as Doeume 9 ? ' nd that I (we)
pne�sent,Yy own the pnaposed site {o ewa e s system (on I (we) have
obtained an easement, to nun with dm nibed pnope4ty, bon the
constnuetion oA said system, and the same has been du,2y recorded in the O�4ice
o edd, ab Document No. ) .
SIGNAT RE 0 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
•� i y 8
DATE SIGNED DATE SIGNED
DOCUMENT NO. WARRANTY DEED
STATE OF WISCONSIN—FORM 9
TIM SPACE RESERVED FOR REC OMC.DATA
293545 eou 445'' nrM
THIS INDENTURE Ma0e by__J�Y B. Christopherson and REGISTERS OFFICIr
_ _ Stella__.,L. .0 Iristo�...... . husband and wife ST. cROlx co., wls.
.........................................•--°°°°-•-.............._.... ncCr(j fnr Rurnrrl f{iiq 30th
k ,01tti Wmonsin,hereby conve,v at��, t l 1•r'.,
r and Sandra_ .
L. Bensen,
and wife. as ao>nt tenants _
......................................................... � -
Regfster.......................................................................................................................................................
............. ............ ........................... .....grantee..9....... RETURN TO
............................... ....................
of.........5t . Croix coun ,Wisconsin,for the sum of
One Dollar 051.00) and other valua le con-
,.... ......---.•.......o............._....................._.._............... ............
ST iderat ion
the following tract of land in..._-.._St. Croix County,State of Wisconsin;
The Northwest Quarter (NW4) of Section 36, Township 31 North, Range 17
West, except the following tracts of land:
I�
(1) That tract of land sold to St . Croix County for highway pur-
poses;
(2) Starting at the Northwest corner of the Northwest Quarter of
the Northwest Quarter (NW%4NW4) of said Section 36; thence
twenty (20) rods East running parallel to State Trunk Highway
64; thence South sixteen (16) rods; thence West twenty (20)
rods running parallel to the North line of said section; thence
North to the point of beginning, containing two (2) acres, more
or less;
(3) That tract of land sold to Eunice Jones and described in that
warranty deed recorded January 23, 1963 , in the St. Croix I
County Register of Deeds Office in Volume 391 of Records on
page 508, as document No. 271390;
(4) Commence at a R/W Post set on the intersection of the North and
South 4 line of said Section 25 and the South R/W line of S .T.H. !
64, said post being 1282' South of the North line of the SE4 of
the SW4 of said Section 25 and the point of beginning for parcel:,'
to be described; thence proceed South along North and South 4
line of said Sections 25 and 36 a distance of 388' to an iron
pipe set on a meander line of the Willow River; thence proceed
N 530 04' W along said meander line a distance of 206.42 ' to an
` iron sake; thence proceed North and parallel to the North and
South 14 line of Sections 25 and 36 a distance of 264' to an iron.;
j (Description continued on Reverse Side) i
*Yj •. r s ,. ve , their s , s
iiI'_ti WITi....,S WH iltlsvF,the sari•�•.,ntor._....._..,a. ..._._hcrwnto ;c.t..... .........hard............and sca....... ....this.... .. 'I
day(,f..August.. ..._- ,A. I)., 19 68
j SIGNED AND SEALED IN PRESENCE OF l � '� fir--(SEAL)
- Ray- B _...hristopherson
•
(SEAL)
G. E . Norman Stella L. Christopherson
............- ----- ................. ..... ............. ...... ........ . .. .. ..
� r
SEAL) !I
__
Linda Sharretts (SEAT,)
................-----------------•--......--•---......
STATE OF WISCONSIN, 1
St-_. Croix J}as'
.................... ..... ................ ...........---County.
August --..68
Personally came before me,this................... ...�' ....._('av of.-.-I——........---.---. ...._._........._... __.... A. D., 19
the above named.......Ray.--.B......Chr.i..st.ogher.son.-.and.._.Stel.Ia__.L..-.--Cbris-t.opbe-r.son.,__.husband..-.-.--__-- �
,I
and wife, �•.
.. ... ..- -•-
----- - - _. ..:..:: -
to me known to be the person.$-..who execute..•tlie forejoiag•instrument and acknowledged the same.
G. E. Norman... _....._
UICA -•..........................----
i
This instrument drafted by `' Notary P ublic__St. Croix ._County,Wis. I!
gOAR-,(_-DRILL & NORMAN __ q•i My Commission(181*IlS�9Q (Is)_..pexmaXlerit_—__.._ �
--- -
--.....�
— I
(Section 59.51 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly Printed or typewritten thereon the i+
names of the grantors, grantees,witnesses and notary).
WARRANTY DEED—STATE OF WISCONSIN, FORM NO.9 H.C.MILLER co.,MILWAUKEE
I �I
Skiii i 61 Wk&siri
County of St. Croix
I hereby certify that this instrument is a full,
true and correct copy of the document on file
and of record in my office and has been
compared by me.
Attest.... Jun 1 , 19_, LL
James 0' onnell
1ramea C7 Connell Register of Deeds
Deputy
4
293546
Pipe set on the South line of said S .T.H. 64; thence proceed
East along the South line of said S .T.H. 64 a distance of
165 ' to thepoint of beginning.
/ l �a
a BOOK 445 FAGE273 `� \�
H
H
y
' r
ST C - 105 r
9
y
SEPTIC TANK MAINTENANCE AGREEMENT 0
St . Croix County
d
9
H
OWNER/BUYER
ROUTE/BOX NUMBER _5
Fire Number
C I T Y/S T AT E_-AL",, i '4/l✓ rl >- L 1 P
41),-- f4, Section_ , T / _N , R�-W '
PROPERTY- LOCATION : ,
Town of , St . Cro-ix County ,
Subdivision � 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
nec-
essary) , the septic 'tank is less than 1/ 3 full of sludgelordtocum.
Certification form will be sent approximately 30 days p H
three year expiration . °
E
I/WE , the undersigned , have read the above requirements and agree x
to maintain the private sewage disposal system in accordance with
the standards set forth , herein, as set by the Wisconsin Depart-
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County i g 0 fic 4ithnin 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
Sign, date and return to above address .
N6UST Y,-, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
NDUSTRY,_. , , c DIVISION
-ABOR AND PERCOLATION TESTS (115) MADISON WI 7969
I.UMAN REJ.ATIONS
(H63.09(1)& Chapter 145.045)
OCq I N: SE TOWNSHIP/MUNICIPALITY: OT 1SUBDIVI ON NAME:
�:QUNTY: OWNE AME: AILI ADDRESS i
l
- '� . 1
JSE DATES OBSERVATIONS MADE
NO.B7 C N A I TESTS:
!Residence El Replace I / �Y
tATING:S=Site suitable for system U-Site unsuitable for system
.ONVENTI NAL: MOUND: IN-GROUND-PR S EM-IN- ILL OLDING TANK:RECOMMENDED SYSTEM:Ioptional)
Es nu ®S au� ®S ❑u CAS VJU ❑S IZU
It Percolation Tests are NOT uir re DESIGN RATE:
4 I If any portion of the tested area is in the
u /
nder s.H63.09(5)(b),indicate: 1 Floodplain,indicate Floodplain elevation:
L,l- /r PROFILE DESCRIPTIONS
CORING TOTAL ELEVATION P R U ATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
DUMBER DEPTH�I, S RV H EST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
13- / /. >
13-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD1 PERIQ PER Lgiv 3 PER INCH
P- /
l
N-
I'-
LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
,ntal 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
I land slope.
')YSTEM ELEVATION
I ,
I
f _
I
_ r
SU�
1
f
l i I
TN
I ,
the undersigned,hereby certify that the soil tests re orted on this form were made by me in accord with the procedures and methods specified in the Wisconsin
,dministrative Code,and that the data recorded and the Inicatop of the tests are correct to the best of my knowledge and belief.
io
iAM not TESTS WERE COMPLETED ON:
�D E$S: CERTIFICATION NUMBER: PHONE NUMBER(optional):
C IG T E:
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
,I L HR-SBD-6395 (R.02/82) —OVER—
,tlsuSG
�a
y�
A4,
l
49129
i
l ,
ojyao
SL6I ` PAGE OF
��G1y�cT�� W <� 7 /
IUD' CroSS .7ecllut, o � A Sys �en-
ti
Fresh Air Inlets And Observation Pipe
�f---Approved Vent Cap
Minimum 12"Above
Final Grade
20-42"Above Pipe _4"Cast Iron
To Final Grade Vent Pipe
Marsh May Or Synlhetk Covering
win 2"Aggregate
Over Pipe
Olefrlbutlon —Tee -
Pipe _� 0 0 0 0 0
B Aggregate o Perforated Pipe Below
Beneath Pipe
o —Coupling Terminating At
Bottom 01 System
Pro ose I) PI��_1 �r,,.fl< , I
ton
Sol ILL
DISTRIBUTI V PIPE
• APPR.OVEO S'jMTHETIC DOVER
OP 1. OF STRAW
ZN OF hfi6REGATfi —fir OR MARSH HAy
(o . F�^-Z14, AGG E ATE
ELEV. OF .� FEET—,
DIS-1-Rlgi_1TICM PIPE TU BE AT LEAST I' '_ IIJCHES BELOW ORIGIAIAL GRADE
A►JU AT LEASTZO INCHES BUT AIO MORE THAIJ 42 IAICHES BELOW FINAL CsP.ADE
.0
MAXIMUM DEPTH OF CXC/WAT100 FROM OWMAL 6KAoF. WILL BE //7 � INCHES
J'ONIMUM! ®EPTM OF EXCAVATION fKOM 01KI61WINL GRADE WILL BE INCHES
SIGUED:
LIGE►JSE AIUMBER: lJ ��
i
DATE : � . � ��
PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VENT CAP
H"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MANHOLE COVER
25' FROM DOOR,
WINDOW OR FRESH 12"Mlu.
AIR INTAKE
GRADE
I y"MIN.
10"MIU.
CONDUIT -- ---_-----
10"MIN. \ ----------
IAIL.ET PROVIDE I -----
w AIRTIGHT SEAL
APPROVED JOINT A I I(I APPROVED JOINTS
W/C.2. PIPE. I III W/C.I. PIPE
EXTENDMIC• 3' I II ALARM EXTENDING 3'
QIJTO SOLID SC;:. B I I ONTO SOLID SOIL
c
I ON
i
PUMP— , --�
OFF
CONCRETE BLOCK
RISER EXIT PERM11TE0 OML`J IF TANK MANUFACTURER HAS SUCH APPROVAL
SPEC.IFICATIOUS
SEPTIC AND t
DOSE TANKS MANUFACTURER:1" ' Lw NUMBER OF DOSES: PER DA4
TAWK ;IZE: ZOO // GALLONS DOSE VOLUME
ALARM MANUFACTURER: ��,�� �1ti+. . "�, ,{ INCLUD!&!,, ZAC! FLOW: GALLONS
MODEL IJUMBER: CAPACITIES: A= IMCNES OR 7�1_ GALLONS
SWITCH TlIPE: fZz. 5= --? INCHES OR GALLOWS
PUMP MANUFACTURER: C: 7 INCHES OR �.L GALLOWS
MODEL NUMBER: D- INCHES OR GALLONS
SWITCH TYPE: 'L/ MOTE:_ PUMP AND ALARM ARE TO BE
PUMP DISCHARVE RATE GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFEKEMCIE Bi11'WGEIJ PUMP OFF AND DISTRIBUTION PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURTT,E//. . . , . . . . , . . 2.5 FEET
♦ FEET OF FORCE MAIN X F/oorr.FRICTION FACTOR.. FEET
TOTAL OyNAMIC. HEAD = / FEET
Al
INTERNAL QIMEWSION T UK: LENGTH ;WIDTH -- ;LIQUID DEPTH
SIGNED: LICENSE NUMBER: .1S";13 DATE:
-11�-
D fM NT OF INDUSTRY, FNSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
MADDISON,,W,1 53707
PAOX BUREAU OF PLUMBING
W,1
[MONVENTIONAL ❑ALTERNATIVE I State Plan l.D.Number:
❑Holding'Tank ❑ In-Ground Pressure ❑Mound [f If assigned)
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Allan Benson R. R. 3, New Richmond, WI
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV,.
NWT NWk Section 36, T31N—R17W, Town of Stanton
Name of Plumber MP/MPRSW No.. Coumy: Sanitary Permit Number
Cal Powers 1563 St. Croix 54922
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
1OYES ENO OYES ENO
BEDDING: VENT DIA.: VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: IAIR INLET:
DYES ONO DYES ❑NO N.EARI:ST
DOSING CHAMBER:
MANUFACTURER: 71Y-NGS LIQUID CAPACITY. JPUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
JPROVIDED: PROVIDED:
E ❑NO OYES ONO 1 ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF -PROPERTY WELL. BUILDING.JVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
` _"WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIUE DIA.. #PITS. LIQUID
., E � •s TRENCHES. MATERIAL PIT DEPTH:
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: AIR INLET:
NEAREST
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 ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED J.EPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED'.
CENTER. EDGES.
1:1 YES ❑NO 1:1 YES ONO ❑YES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
�r WIDTH. LENGTH. No.OF LATERAL SPACING:JGRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
>c„NM TRENCHES:
' MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. ID ISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
% .+ELEV.: ELEV.. DIA.: ELEV.. PIPES. DIA.:
AN
HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
DYES ❑NO El YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM, LINE:
❑YES ❑NO ❑YES ❑NO INIEARtST
Sketch System on Retain in county,fale for audit.
Reverse Side.
SIGNATURE: TITLE:
DILHR SBD 6710(R.01/82)
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
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.
L- ' nsln APPLICATION FOR SANITARY PERMIT /►
COUNTY
1 L H (PLB 67) UNIFORM SANITARY PERMIT RTITIEnT OF
TRV,LRBOR 6 HUMRn RELRTIOnS
—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 OWNP MAI ' NG ADDR S
PFIOPIERTY LOCATION CITY:
ti V LLAGE:
/4, Sj . T . N, R IF (O W o j ��
LOT NUMBER BLOCK N MBER SUBDIVISI N NAM AR ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
29 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): Z
THIS PERMIT IS FOR A:
❑ New System Tank Replacement ❑ Repair
i Replacement Soil Absorption System ❑ Revision ❑ Privy
Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
y4 Seepaye Bed ❑ Seepage Trench U 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 ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
r' Private ❑ Joint ❑ Public
I,the undersigned, hereby assume responsibility for installat' n the private sewage system shown on the attached plans.
Namaof P umber (Print)' / Si ur MP/MPRSW No.: Phone Number:
m is Address. I Name of Designer-
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: ate: ❑ Disapproved
�✓ 7� ❑ Owner Given Initial
� Approved Adverse Determination
Reason for Disapproval:
Alternate course(s)of Action Available:
1)ILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber
PAGE OF
✓ V rnSS Szc � 10 p � � r ►� SySten-I
Fresh Air Inlelf And Oo:orvaflon Pipe
P
C: Approved Vent Cap
Minimum 12"Above
Final Grade
20-42"Above Pipe _4"Cost Iron
To Final Grade Vent PIP*
Marsh May Or Synthetic Covering
win. 2"Aggregate '
Over Plpe
Olefrlbutlon
Pipe o 0 0 0 —Tee
Aggregate
Beneath Pipe a Perforated Plpe Below
Be
o 'Coupling Terminating At
Bottom Of System
P�pPOSt �►nkI 9rr,cl< -
L1eJ..T tort we
SOIL FILL
DISTRIBLJY101.1 PIPE
APPROVED S$ANT}+
ETIC COVER
° MATERI^t OR 9" OF STRAW
2"OF MCA EGAIE -� OR (1ARSN HAy
4o'OFJ2-21/2 AGGREGATE
'ELEV OFD/. FEET,
MSTR15UTIOIJ PIPE TO BE AT LEAST I K J CHES BELOW ORIGWAL GRADE
AIJI) AT LEAST20 INCHES BUT 1.10 MORE THAI 42 INCHES 15U:0W FINAL GRADE
P"IMUM DEPTH OF V IOW OM d I&OV p WILL BE �_ INCHES
P H X � AT ROM t� A1. b�A �
PUI41MUM OF-Frh OF ENWIATImN MOM 01k►(.1bAL C)RADf. WILL BE --� INCHES
i
f
SIGI.IED: i I,
l
/ 1
LIGEIJSE f`JUMBER: ;
DATE :
>>o
C
I
Awl
I
I
i YVi
i4 I
of
TF
:Ll I
I u-
r
I
r
V
3 �
• I
E
• I
I �
I
i
i
Wisconsin Department of Health and Social Services
Plb, §67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WfT�U SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check Ones
CITY VILLAGE LEGAL DESCRIPTION
V TOWNS HIP j In!j
lc; S 1
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? X YES NO ��� :=�� PERMIT NUMBER
D. SEPTIC TANK CAPACITY ° ' r �� Gallons NEW INSTALLATION REPLACEMENT ADDITION
V_
MATERIALS% Prefab Concrete , - Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED%
E. TYPE OF OCCUPANCY
Check Ones One or Two Family Residence Commercial Industrial Other
(Specify
Number Number of Persons to be Accommodated Number of Bedrooms
F. ' APPLIANCES, ETC: Food Waste Grinder __ YES °:'� NO Automatic Clothes Washer �-"YES HO
Dishwasher YES ./NO Automatic Potato Peeler YES i- NO
Other (Specify) ?�
G. MASTER PLUMBER MAKING INSTALLA )ON
Name: fj ` .� ! <. - -2:::- :: F � !' + '` tr t( , s
'Ad ress% >` , /:.- � License Number:
*a MP
Signature of Applicant: ` '-, = + ,�..!? ^'" RSW ' ^o
Address%
H. (To be Completed by Issuing Agent)
Date of Application L/ Fee Paid
Permit Issued date ^i J._ 'J
( ) 1 Permit Number _
Agent (Name) / r �C'.-4' �) c /i 'I_ Pori
Town, Village, City,-County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.OU for each septic tanK and the trird 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 pelow — FOR DEPARTMENT USE ONLY
t
I. DATE RECEIVED ' 1 �? ACCEPTED BY i "J �( RETURNED _
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. i �� l ��� PERMIT N0. �l! �• �•1
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or NT
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT N0.
R E P O R T O N ,S 0 1 L P E R C O L A T I O N T E S T I
A N D S O I L B 0 R I N G S
i
TO R ECEI Y rD
DIVISION OF HEALTH + PLUMBDIG SECTI6M
1 an'+
P.O.Box 309, .Madison, Wis. 53701 MAY 14 `j i
f
Pursuant to H 62.20, Wis. Administrative Code rIVISlorf
EAL; R3
P $ R C 0 L A T I 0 N T t 5 T
Test Depth Character of Soil Hours Water
Number Inches Thi•c�asOss in InohOs Since Hole in Hole Interval Second o Wat Next to lashes utcs
Example
1st Watted Overni ht in Minutes Last Period Last Period Period Orse Inch
P " U 36° To Soil 10�� Cla 26f*
25 Yes or No 30 1 2 1 2
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 Absorption System
Baring Total Depth De th to Ground Water De�th�to
Example Bedrock
Number Inohas Observed Estimated Observed Esti¢ated Character of Soil with Thickness in Inches
B 0 72 It 7211
Black To Soil 12"g C 16112 Sand 18,11 Gravel 241
RECORD DATA FROM MINL`4UM OF 3 BORE HOLES
YPE OF OCCUPANCY:
RESIDENCES Number of Bedrooms �
OTTHHF.R�s (Specify)
Number.of Portions
D WASTE GRL*iDERs Yes D1sNaashers Yes
No No f _Automatic Clothes Washers Yes
No
FFLUENT DISPOSAL SYSTEM:
p
F, NEW EXTENSION
- ADDITION REPLACEMENT
Tile Site ',� �""
NO.Lin.Feet Trench Width �-
Depth ''
....:... Number of Lines
Seepage Beds Length Width
e
Seepage Pits Inside D �aae t r Liquid pDeph Tile Size ��Noy Lines
visioIs the undersigneds hereby certify that the Feraolation tests reported on this form were made by me or under
vision in accord with the procedures and method specified in Chapter H 62.20 (13)s Wisconsin Administrativs Code, and
that the data recorded and location of test holes are correct to the best of super-
n
' .' my knowledge and belief.
Type or Print TITLE / ,•' ,� "Vie'.�: ,. y
REGISTRATION No.., ) j
ADDRESS or MASTER PLUMBER LICENSE. N0.
v / _'��� *` ,s._y�
DATE %
i �
SIGNATURE . .'>�!, %-•'�,+! ,° :.� "�°`°
hLLT ad?ud g awnTOA
0 �
uw tia�v • ti w ° `tea
CD E::n UJ C9 CJ G9 d1
LL
'60h00068N ueaq o} pawnsse
g£ UOT438S 10 IMN a4l 30 auij
y�you aye o} paouaua�au a 1e s6uiue0g c =
�/. F— co , aJ
LLJ
LU
LL ° a
O 3
� y
C N
O O N
O to x Y 00
w N <Z N CO m
~ w m M
Z Q . N
w
g Ol
m m O O cz~ t
H O1
Z Z •�
C O >- tU
O — H�.�• 3
U h- Z f
U O N
'HI W O C 0-
Z :3 .rL
-IMN 844 30 autt }sea t0 a
Mu£01L£OON 4) 0 I
L1. L Q1
Q r4 N
CL
7 N = 00
l Tews / C w � O N
•N -, N .rl x O
j 10. £ -<i QNt- J = = c
6801 To ON o M o
41 r-
- 3 coo • O
J1"w3 M O O Z 1� L
Ol..i U •••i L
O.L.i d m
0 x O W i.
oU °D s ao `n\\ *s"fa m�wo cNo
UD z Cl W\ �to jes"e" % rn
w - CD \ HHH
CD co
y ``\ 7
U O I O Y O
O �," 9�\ a •f
4-
CD
0
0
U Ql LO N O 00
00 W +1
\ C
m n O \ E
+� co m 01 m t0 m N tp\ 41
0 LO Z Cl) W N N 2
to •O I \`�
�^ \\ 41
O U - �� U-) U-) \
O
al
f \
O 4- tT N t^0 \ ..
-1
Ku
tU .N I cm Ln O)
L r.{
4- 3
4- N •1
N V
O�0
W
41 Vl — N Cp
O C B.0 r W W W W
7
d I x O O ^ .�i .-+ M N
tU a t0 y s O - •• - - •• - - - -
(�/9 Ln t0 t0 - O O O N O O
0 t0 to O - n N N •--L N 117 01
00 O O .-t O O O
Z L 00 •• m O n r m t0 .-� rr ap
to N t0 m m 0 O m n .-i N n
71M 2M Lc)O Z Cj
F-- D n W 00 N
... ..CaJ' P�1ti.0
M 3u£s19Zot'0S U,
0
18Z'6OZ W a a
3
^I1 I O
�- z W�l 411 w .-al W Lx_ -t t0 h
�/ W col ml N
L.1 "• a ,
�- EI O h-L • • C}
OI J-�I O cr O O /
O O > >
IZZ'79Z cc/0)
1£9'I661 `
3u£519ZotOS IMN a44 40 autj ;saM �1; , ,'•.
1(q pauno spuej paggejdun
t--t w w
o z z �c
W K O H
L— O H O_
w ¢ U H to
U U
V O 3 W C=J Z N cr
995
s a •