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HomeMy WebLinkAbout042-1007-90-000 CD o N o c o v y 0 0 c c 0p Ry 0 0 ts qb cl ts = I s c v v_ 3 N 7cy �E magi o" NOCL oNONNN c d O Oz C.0 O xZ E o aNi N `r° cicow� Ana y N O O O D l9 � Q , oo� 00 y� N LL N N aOL € a c O.O`V N L y E W Cl Oc a or-) O C m w 3 ' o = 0 f: N a� E y o 3• W N N C O N �� c' a_ LL o � � OD 8 m LL 0 ae D 3 3o 0cy'G = �co� aci c o o ` c c c c 0)M C-- E Q H �am0so0s y Q M C) O M N N CO z E E CO � Z _ O :: O z € m v C z a m a m i 0 O Z � c v c a01 z usf- � Q> C E M .fl N N j N N = c m (3) = 03 N N N •� 0 U) L O d N L Q z m z z m z z }}yy O CL .N Y O O. l0 m `l N m 2 N N O 4 N N 0 I. o c a Ea IL CL • aaa z aaa 0 0 a m IL g v Z.; m co 00 0n V ! 3 rn rn z ° 3 z M z N 0 z 0 .-• 0 tE L D L 7 N 7 _ O Co C m O CO C `�i►• 'O rn O m O � 0) 'p _d Q z U) N 0) m Q z U) �r 7 O N N O C y N C 0 o m o a o o 0) E 1 o N N N V 0 06 r O N ;E I-- w - z C N n rn E Y cUi N • , v `° m o O w o m cLi m co D O m 0 O ooh o Z cH � Wl 2LO0 z = z ." v� a d a • ed a m d m c 0) y = rr'1��1 4.+ E L Parcel #: 042-1007-90-000 09/30/2005 08:19 AM PAGE 1 OF 1 Alt. Parcel#: 04.29.18.54 042-TOWN OF WARREN Current X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-MARTIN,CLARENCE P&BETTY R CLARENCE P&BETTY R MARTIN 1189 110TH ST NEW RICHMOND WI 54017 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description ` 1189 110TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 35.000 Plat: N/A-NOT AVAILABLE SEC 4 T29N R18W FRL NW NW EXC NSP R/W Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 04-29N-18W NW NW Notes: Parcel History: Date Doc# Vol/Page Type 05/13/1999 603104 1426/265 QC 131957 161/216 WD 2005 SUMMARY Bill M Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/11/2003 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 28.000 3,300 0 3,300 NO UNDEVELOPED G5 2.000 200 0 200 NO OTHER G7 5.000 15,000 137,600 152,600 NO Totals for 2005: General Property 35.000 18,500 137,600 156,100 Woodland 0.000 0 0 Totals for 2004: General Property 35.000 18,500 137,600 156,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 307 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 9EPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS L4BOR BOX RELATIONS PRIVATE SEWAGE SYSTEMS P.O.O.BOX 7969 969 DIVISION BUREAU OF PLUMBING MADISON,WI 53707 NW ,NW 4jS4,T29N—R18W IS,,,,Plan LD.Number CONVENTIONAL ❑ALTERNATIVE (If assigned) Town of Warren ❑Holding Tank ❑In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Clarence Martin Route 4, New Richmond, WI 54017 `, -g'7 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF,PT.ELEV.. Permit Number: Name of Plumber MPlMPRSW No.: County. Sanitary William Schumaker 6382 St. Croix 102796 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV_ WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. OYES ONO [—]YES ONO BEDDING VENT DIA.. VENTMATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. IBUILDING. JVENTTOFRESH ALARM FEET FROM LINE. AIR INLET ❑YES ONO OYES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER IWARNINELABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO DYES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING IVENTTO FRESH LINE Al.INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) OYES 0 N NEAREST N. Sol L ABSORPTION SYSTEM.Check the soil moisture at the depth ofplowing LENGTH IDIA111TER IMATIRIALANDMARKwc, 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: L NO.OF .PIPE SPACING COVER INSIDE CIA SPITS LIQUID BED/TRENCH TRENCH COVERIALI PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL EPTH UISTH PIPE DISTR.PIPE IPE MATERIA L: NO.DISTR NUMBER OF PROPERTY WELL BUILDING. VENT TOF HE SH BELOW PIPES. ABOVE COVER. ELEV INLET ELEV.END. PIPES FEET FROM LINE AIR INLET NEAREST--,I 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. 1:1 YES ONO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. DYES ONO OYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES ❑NO ❑YES ❑NO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV.. ELEV.. CIA.. ELEV.' PIPES DIA.. DISTRIBUTION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS EYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATIO WELLS: NUMBER OF PROPERTY WELL: jBUILDtNG: FEET FROM LINE DYES ONO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE Zoning Administrator +I DILHR SBD 6710(R.01/82) [ J 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 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: 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 ##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'h 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 Ground atr included the creation of surcharges (fees) for a number of regulated practices which Wisco En can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasurs a is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper., o 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) DILHR SANITARY PERMIT APPLICATION C C/2�� In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# �da7� —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 5r NO APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES Lr NO PROPERTY OWNER PROPERTY LOCATION v,e,/_a.e- v i,,,r/ ,tW% 'Cldl" S 41 T 17, N, R J F_ E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE P.v c" ZIP COD PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK e Y7 5r-TOWN OF6 ZJ�yj-eAl ❑ VILLAGE II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b. 29'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. 9 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. 9 Seepage Bed b. ❑seepage Trench c. ❑ See a e 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): oqf If u Feet Private EI Joint ❑ Public VI. TANK CAPACITY Site in aallons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank ❑ I TETHE Lift Pump Tank/Siphon Chamber ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system hov jil on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) P PRSW No.: Business Phone Number: Zal F�2 37a Plumber's Address(Street,City,State,Zip Code): Name of Designer: I VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)N me CST# ZY PIZ/ CST's ADDRESS reet, ity,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial c�ha�rg-e+Fee Adverse Determination /��•�� c�J• QJ �� 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 APPLICATION FOR SANITARY PERMIT STC - 100 I This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property � ae e v e-e- ef u�-7,;P,4,1 Location of Property 42Z1_ / , Section , T N-R /�W Township Hailing Address AT'Z/ Address of Site T Subdivision Name . Lot Number �— Previous Owner of Property , Total Size of Parcel s i a, re y Date Parcel was Created M x.—z P� �Op� Are all corners and lot lines identifiable? Yes X No Is this property being developed for resale (spec house) ? Yes _�_ No Volume __ and Page Number Sa a as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ee ti.6y that aU 6tatement6 on thi,6 6onm ace t ue to the but o6 my (oun) knowledge; that 1 (we) am (ace) the ownen(s) o6 the pnopenty de6cA bed in thi.6 in6oAmati,on 6onm, by vixtue o6 a waAanty deed neconded in the 066ice o6 the County Reg4Aten o6 Veeds ass Document No. 3.�2 7/Ge ; and that I (we) pAu en tey own the pnopobed 6 to bon the sewage dispodpod z yes em (on i (we) have obtained an easement, to Aun with the above de cAibed pnopehty, bon the eonataucti.on o6 said dye.tem, and the bame ha.s been duty tecotded in the 066ice o6 the County Reg.iateA o6 Deeds Document No. a�/6d 1 . SIGNATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED x ws H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z cy a H OWNER/BUYER �,�qtr ed[C P_ ,����'T. � M ROUTE/BOX NUMBER7` t( ,��,,_j Fire Number .CITY/STATE 'e'lecJ �r�'e�l�+a,,�e� �,J� ZIP PROPERTY LOCATION:,,e/Gf 'k, fit, Section Y T N , RAW, Town of St . Croix County, Subdivision , Lot number ' I 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 I/WE, the undersigned , have read the above requirements and agree z„ to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- o ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoni / ffkpe withi 0 days of the three year expiration date. 1 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. DI:3US TM OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, BOX 7 UN LABOR AND PERCOLATION TESTS (115) MADE SO,WI 53707 HUMAN RELATIONS (H63.09(1T&Chapter 145.045) N ' MUNICI PALITY: T O. LK.NO.: SUBDIVISI N NA E: � � 29 N/R/80(a Q� n1 CQUNTY: W A MAILINU ADDR C�nteE �E n�I�QT► _ Rr 4 n/�i �I<IaMON� l USE DATES 09SERVATIONS MADE T O p� Residence uN� ❑New Replace e CRr LZt�9S7 SF�T 2 3 SOILS K 441 S / Sobs Sh B - SA71-te RATING:S-Site suitable for system U-Site unnsuitab=SOU le for system Q ICQN—VEN MOU DU VL ❑J TA K: ECOMMENDEDOS✓YV A!` tional) I If Percolation Tests are NOT required DES GN RATE: If any portion of the tested area is in the under s,H63.09(5)Ib),indieste: CLASS lFloodplain,indicate Floodplain devotion: A Nt:4 rt PROFILE DESCRIPTIONS BORING TOTAL A E -1 A R OF SOIL WITH THICKNESS,COLOR.TEXTURE,AND DEPTH NUMBER ELEVATION _EST. TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) I '91.0% Ze'e v4 39`6401V Mss 94VAS Rk ok ES r <,,S,S L zx'+ee� �sW�'Ut 6"i9PgVs 4,qn FS B- 2 95aC > 9.s8 "Au-.rs rVIA'vSr "4V 9 S B- 7gR� S Q . St ,CiY7 /9"P eA YFS LESco I A-16" peoM S t 4£ �' �4 n75�62 � }tijS A',Wl„ k �S o¢ "'t ' �T ~� PERCOLATION TESTS YL i of THE h/CSy Si v- a - 94044 RI0V TEST DEPTH WATE TEST TIME RATEM INCH S NUMBER ►NOWS AFTERSWELLIN INTERVAL-MIN. PERIOD 3 P_ 3778 0-1L- /7 04 .4 P- P- 3,S2 5.3Z 1 a P L �5•T/ - !7 y Ct,.� e o�1 RL PLOT PLAN: Show locations of percols�ion tests, soil borings and the dimensions of suitable sail arses. 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 su rcent V .!1! r arrr•�P • r/i of land slope, SYSTEM ELEVATION y / o i 'A L r } Ems, S S? M !KS, NCV1. $c MQVIr As FRoot Y TN TO;TNT.... A s�r �S � �;a.� „�,,,., • �eI � � S T k cr �j%SI 9 L lrj S J° q.1 /7lr • , N 9 3 i _�, SITE Loclttlorl � =�3Sr z LNCQMAPP. - WcoD Co N � 11.E OrAAPlokim+C�c LecK�ton/ o� -rQp. C? / AOi._. r EaiSTiniC,� SEATI 1 NlZ Ls I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NA71Aprint TESTS WERE COMPLETED ON: �E�� JouNSt)04 1Pu`x.IJ 54�YEi,N�> f'n/o__�� S+;.lar 23 09 7 ADD ABS: , CERTIFICATION NUMBER: PHONE NU BERloptional): �-7 <5 t, :wyA, ":',7 �,( I'v 4o 1 >4 4 SI ATURE: DISTRIBUTION:original and one copy to Local AuthnritY,PrnPcrtY Owner and Soil Taste(. DIL.tw ,,fit)-6395 1R.02/112) -OVER - 6��b N , t DEPART MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P�O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 ❑CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: (If assigned) RECONNECTION El Holding Tank El In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: MaAt n, Uanence P. RR#4, Box 57, New Richmond, w1 54017 BENCH MARK(PerSection eference Poi SCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV. NW NW, 4, 29N-R18W, Town of Walr en Name of Plumber: MP/MPRSW No.: County Satritary Permit Number: GoAy Steet 3254 S Cno%x 5&8G7 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: ITANKOUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ❑NO ❑YES ❑NO BEDDING: VENT DIA.. VENT MATL.: HIGH WATER N BE''(j . ROAD: PROPERTY WELL: BUILDING:JVENTTOFRESH LE ALARM. LINE: AIR INLET: FEET FROM DYES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MA NUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: EYES ❑NO EYES ❑NO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NQIMSER'..OF' .PROPERTY WELL: BUILDING.I VENT TO FRESH (DIFFERENCE BETWEEN FEE'[ FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENCrH DIAMFTER MATERIAL AND MARKING Or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH NO.OF DISTR.PIPE SPACING. COVER INSI DE CIA. #PITS. LIQUID 'I�D/TRENCH TRENCHES. MATERIAL: PIT DEPTH. c�rMEres�e�l�s GRAVEL DEPTH FILL DEPTH IDISTR.,PIPE. DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR NUMBEROF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES- ABOVE COVER. ELEV. NLET 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 1:1 NO SOIL COVER TE xTUR E. PERMANENT MARKERS. OBSERVATION WELLS. ❑YES 1:1 NO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =1 TOPSOIL. SODDED JSEI:UED MULCHED: CENTER. EDGES-. DYES ❑NO DYES ONO IOYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: .',SEPITREMCK: TRENCHES: DIMEIVSFONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV. ELEV. CIA ELEV.: PIPES. DIA.: ^EsLEVATION AND HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED INFORM1AT14 PLANS DYES ❑NO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: IN UMBER 0 PROPERTY WELL: BUILDING: FEET FROM LINE: EYES ❑NO : YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DI LHR SBD 6710 (R.01/82) r 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. 17 U conS,_ APPLICATION FOR SANITARY PERMIT . ' D'L H R ' COUNTY (PLB 67) UNIFORM SANITARY PERMIT# STRV,LRBDQ 6 MUTRI'l RELRTIOr15 - D O 46 —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system,on paper not less than 8'hx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROP RTY OWNER MAILING ADDRESS PROPERTY LOCATION C+T-Y: V LLLAGE r� 1/4 i�Gra/4, S , T�� . N. R �? `(or) W TOWN OF: LOT NUMBER BLOCK UMBER SUBDIVISION NAME T AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER I � 1 - /y -r- TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Sip amber Holding Ta apacity Ma acturer• 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 Sipflon Chamber M acturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 4— j(,, j f 1, ❑ Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation/9f the private sewage system shown on the attached plans. Name f Plumber (Print): Signature: / MFr/MPRSW No.: Phone Number: �`' � � r-- � 1, �� � �r;�� <��' `� � (�_-� ►lye �cF;�. Plumber's Adylress: / Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: El Disapproved 17 j�,p /� ���ny E] Owner Given Initial � d"� Approved Adverse Determination Reason for Disapproval: Alternate course(s)of Action Available: DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber �\ . \z � m - k 2 0 2 2 F 6 q \ 14o E 0 0 2 ■\ = k c 4) � ■ %j c c 0`0 _ 2 � t � � � R » c am 222 we r 0O 'D = k� � UA 0 c U) 2 o 0 Q m2 � 2r o� � r (DrV E §� � � � � � � kk 0 0q CL U) 0c'ov_ © 0_ ® 0t0 m _ o ■ o ■ 0z � � 7 � & � � 3 OC Z © aCL2c 00 = § kt2 � = d O » -a 2k S � 0 §� 0 © & .5 c � a a � � $ _ c % ' © 0 c 0 c . ■ d at - cc 030 ƒ 50 9" E $ c � � � 0 © Cd 3mm § 2cc 6 ) c % cm cm � & 2 . - 0 ■ o 0 " $ CM c - 0R u0kk ■ _ts § 2 $ -19 0*0 0. ,0 7 5 0 » e © § � c0 cm E � >% ■ % % o o �o o ■ c v 22 ƒ 0 © 2 c o M w w 2 § q = $ O § � ■ ■ _ - e ■ a � ■ § INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate sail test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 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; Bs Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; . 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; 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 CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock 61 cob - Cobble (3- 10") SS - Sandstone 2 / gr - Caravel (under 3") LS - Limestone *s - Sand HGt1V - High Groundwater 4 cs Coarse Sand Perc -- Percolation Rate need s - Medium Sand W -- Well I's Fine Sand Bldg - Building Is Loamy Sand > - Greater Than sl - Sandy Loam < - Less Than "I - Loarn Bn - Brown *sil - Silt Loarn BI - Black si -- Sift Gy - Gray cl - Clay Loam Y - Yellow scl Sandy Clay Loan. R - Red siel - Silty Clay Loam mot - Mottles sc Sandy Clay wi - with sic - Silty Clay fff ..._ few, fine, faint xc - Clay ce - cornrrron, coarse pt Peat rim - Many, medium to - Muck d - distinct p - prominent HWL - High water level, Six neneral soil textures stir-face wafter for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Paint T O THE OWNER: r hs <- sail test report is rile first step in securing a sanitary peirrut. 1h¢, county or the Depaflrne,E_rwly remiest yr tars =oil test its the f;nld prior, to pr"t-mii issu,,r?c, �� c;;�rntaleTe set of I:71ar�., f„ thrt }rr�vate sevvd e� r,nd '� "ietm,t. ;ipplrcalw)n rnost be stibmrtted to Hw apr);op iale coca, .rc;€,} c)rity' i:1 order c -mow DEPARTMFFNT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND C P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707 (H63.090)&Chapter 145.045) LOCATION: SECTION: TOWNS HIP/MtffftetPA=Y: OT NO.:BLK.NO.: SUBDIVISION NAME: W � l 1 = � ` N�R��a y(or), ,Z y• .t G�r. 2'' OU TY: NER'S BR'S NAM MAILING ADDRESS: - USE 1bATES OBSERVATIONS MADE NO.BEDRMS.:1COMMERCIAL DESCRIPTION: ❑ LPROFI L D S RIPTIONS:1PERCOLATION TESTS: esidence h New ❑Replace i.. RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND. IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) s ou [Q s ou �s ou ❑s u os �u , If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: %� Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS C - BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES f AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD PER INCH P- P- P- 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 and the direction and percent of land slope. It SYSTEM ELEVATION t ri 6 I } 9 ��. �• i - — � 1 7 1 t _ 1 _ 1U j � l I I _ ------ � 7 71 5 I ° � i _ ,t 4 ( _ � _ ........... _ - I I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): ) TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): I CST SIGNl TURF: DISTRIBUTION: Original and one copy to Local Outhority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — Forul - S T 'C• 1QG J Owner of Property .Location of Property Sect o ,T N R W Township Mailing Addres Subdivision Name Lot Number Previous Owner of Pr erty Total Size of Parce Date Parcel Was Cre ted Are all corners id ntifiable? Ye o Include with this a licati n one of the fo ow n : . Certified Sur ey Map . Dead . Land Contrac . or . Other Vagal ocument w ich descr bes the ropert PROPERTY OWNER CERYIFI ION i I (We) certify,nat all statem nts on this rm ar true to the best of m (our) knowledge; that I (we) am ( re) the ow r(s) the p operty describe in this informrp ;on form, by virtue of a warra ty ed recor ad in the Offs of the C"".ty Register of Deeds a Docume t N . ;and th I (we) presently own the propo site for a wage disp sal system (or (we) ave obtained an easement, to r n with a bove descri property, r t construction of said syste ,and a me has bee duly record i he Office of the County Register of Bed ,as ocument SIGNATURE OR OWNER IGNATURE OF CO-OWNER (IF APPLICABLE) DATE STONED DATE SIGNED VIA'