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HomeMy WebLinkAbout042-1040-95-000 C °N ° a) N O y 00 oQ 0 o 0 0. 0 0 0 4 p LL u1 00 O O CD N L .L. N @ C N@ W a "O O@ C@ °� > o 00 m uci ~°Zv° y= E Y n o .q a) r- 00 LO E yUCQ @ `y @@ N N C C a) 0 3@ 72 _ . N tt N W O O W Ca a N U O In U N L cn co C O EO 4 a) •X a)0 C N O h w� c a)w a)rn N 3 rno.0 N o a� a) . o a)L N o E •C-L t r- o@ o c T- a) 3 o y U � @ II' N C O 'a Z Co a1 EO a) @ C)Y•� N C N c cy c @ LL `@ aNCU) Xx LL C N CO E LL N a) N LL C C C a) O c O E O N N-p V' O Q) > p @ _0 N U> a) () a) a) a) a) O Q 0 N@ Q Ll. E Q L L..(n L@ N c U V V N 4) O Z tll N � �• ' £ a I Z y a) d a7 a ) in N w a m a Co c I ° i m c t9 0 c c U O Z d' c c - c w o o o r o Q) N _ Cl) a) 7 N N a y C N N c @ N ) O O •MV Q. ca) .c d N L D.. 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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 ANNEXED PARCEL MUELLER O-MUELLER,ANNEXED PARCEL Districts: SC= School SP= Special Property Address(es): "=Primary Type Dist# Description SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 8.300 Plat: N/A-NOT AVAILABLE SEC 15 T29N R18W PT OF SE SW&SW SE. Block/Condo Bldg: THE S 975 FT OF W 1300 FT OF E 3465 FT OF S1/2 SEC 15EXC S 990 FT OF W 220FT OF Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) E5/8 OF E1/2 SW 1/4& EXC P236E AS IN 15-29N-18W VOL 638/15 ANNEXED TO VIL ROBERTS NKA 176-1069-90(513) Notes: Parcel History: Date Doc# Vol/Page Type 09/10/2002 689892 1973/250 WD 05/16/2002 679240 1892/465 ANNEX 07/23/1997 638/15 2007 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/31/2002 Description Class Acres Land Improve Total State Reason Totals for 2007: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 PUMP CHAMBER s Manufacturer: 1j,��s Liquid Capacity: Pump Model: Z ll-ez s-3 Pump/Siphon Manufacturer: Pump Size — Elevation of inlet: 1rS, Bottom of tank elevation: Pump off switch elevation: Z �i, Gallons per cycle: S'00 Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: .T Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: t/ Trench: Width: Length:_�� . Number of Lines: -� Area Built:. Fill depth to top of pipe: �� N Number of feet from nearest property line: Front, O Side, Qear,O Ft . , Number of feet from well: 7 /DO Number of feet from building: 7 4y (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: �/ Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: -'',, Inspector: fyc�h c', Dated: 7 Plumber on job: 'Z License Number: DAVE FOGERTY PLUUNNG Licensed Perk Tester & Plumber 33233 33289 Fo rty He Road 3/84:mj ROSE 9,WI y�t9 .36 N 54023 one Form - r AS BUILT SANITARY SYSTEM REPORT OWNER 4 � TOWNSHIP vt/ SEC. 1,� T 2 ADDRESS �c� �.� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING JITHIN 100 FEET OF SYSTEM RF '� /YXN off Ci k L•s' Ss �3 62 L, i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used �' ���. J Elevation of vertical reference point: lB4.Q Proposed slope at site: / Ld SEPTIC TANK: Manufacturer: �,CC�-f Liquid Capacity: �� Number of rings used: _�_ Tank manhole cover elevation: Tank Inlet Elevation: 2L, 7 Tank Outlet Elevation: ,y6 Number of feet from nearest Road: Front 10 Si.de,o Rear,<0 ' /,,re feet From nearest property line Front 10 Side,0 Rear,0 �,/d D feet r Number of feet from: well v�'� building: Se-e (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 PRIVATE SEWAGE SYSTEMS DIVISION MADISON P.O.BOX 0 BUREAU OF PLUMBING 5 =W WI 53707 4S15,T29N-R18W CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: Town of Warren ❑ (If assigned) Holding Tank ❑ In-Ground Pressure ❑Mound Hwy. 12 7­747- 0 Y NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSP TION DATE Phil Brown P.O. Box 454, Fall Creek, WI 54742 ;Z` BENCH MARK(Permanent reference point)DESCRIBE IF DIFFER F NT FROM PLAN: R . REF. �Cw J r-� ,t PT ELEV.: CST REF.PT.ELEV.. Name of Plumber i IMP/MPRSW No Counry Sanitary Permit Number: Dave Fogerty I 3289 St. Croix 96011 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: I❑YES ❑NO ❑YES [ No BEDDING: VENT DIA.: VENT MATL: HIGH WATER INUIUIBER Oi-" ROAD: PROPERTY WELL: BUILDING: VENT TO FRESf ALARM: FEET FROM LINE: AIR INLET: DYES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING. VENTTOFRESH (DIFFERENCE BETWEEN FEET FWpM LINE AIR INLET. PUMP ON AND OFF) DYES ❑NO ARE$T. SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTFI1 DIAMETER 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: �■���L I WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA.. #PITS. LIQUID ° a`F4li TRENCHES. 999 ATERIAL: PIT DEPTH. GRAVEL DEPTH FILL DEPTH IDISTR.,PIPE DISTR PIPE DI R.PIPE MATERIAL: NO TR NUM ER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. AB E COVER: ELEV. NLET ELEV.END. PIP S LINE: AIR INLET: I y� FEET FR#NI MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER ITEXTURE p ERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO DYES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =OIL. SODDED. SEEDED. MULCHED: CENTER EDGES. DYES ❑NO DYES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: b 8 d @ N WIDTH: LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: e �"�° � TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: JNO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.. ELEV.. DIA.: ELEV.: PIPES. DIA.: af}� HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED f p PLANS [:]YES NO YES--- NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NppP ROPERTV WEL BUILDING: LINE: DYES ❑NO ❑YES ❑NO NAFt T. U ok Sketch System on I R/coun audi t. Reverse Side. SIGNATU E: 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. AW revisions to this permit mdst,be approved,by the permit issuing authority. A new..pe,rmit may be needed if there is a change in dour 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 sy-stems must be'properly maintained. The`septic tank(s) shoultl b 'pbmped by a licensed- pumper whenever necessary, usually every 2 to 3 years; 6. ".f yc.; have questions concerning your privat,) sewage system, contact your local code adrni sir trator or the State of Wisconsin, Bureau of Plumbing, 608-266-3816. �y To be complete and accurate this sanitary permit applica':ion must include: !. Property owners name and mailing address. Provide the legal description where the system is to be installed; II. Type-of btrdin 9,or use served: If public is checked, indicate type of use (i.e. 10 unit a artmeni, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; M. 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'/Z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment Tanks; building sewers; weFls; water'rriaihs/water service; streams and lakes; dosing or pumping chamber's; distribution bo)tes; soih 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 - common!y,known as the groundwater protection law. This change in statutes was the resuit of over•2•years,,&.steady negotiation�anb`public debate: The,g oundwater bill GrouTid At It _ included the creation of surcharges (fees) for a number of regulated practices which Wisco xrt`y a 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 tc the groundwater through your soil absorption o } system or the disposal site used by your holding tank pumper. a The -non:es collected through these surcharges are credited to the groundwater fund adm nis- loreer by the 'department of Natural Resources. These funds are used for monitoring grow d- t Gvater, groundwater contamination investigations and establishment of standards. Groundwater, it's wort", protecting. SBD-6398(R.03/86) Q�V (—�, — SANITARY PERMIT APPLICATIOR COUNTY LI �ILHR In accord with ILHR 83.05,Wis.Adm.Code D> X —'°""'""°" ""mmm STATE SANITARY PERMIT# 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 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ® No PROP Y OWNER PROPERTY LOCATION '/4 W'/4, S T , N, R E(or P OPER OWNER'S MAILING ADDRESS LOT NUMBER IBLOCKNUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER Tn CITY NEAREST ROAD,t'_WS ORtA?IBMA iK / I VILLAGE: II. TYPE OF BUILDING OR USE SERVED: O Number of Bedrooms if 1 or 2 Family y OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. El �l New b. Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. 2�A Sanitary Permit was previously issued. Permit## 2&f y Date Issued 9//O/tea 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. L�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) LJ 1. a. See a e 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): �/ 3 ,Z .� Feet 5 t'rivate ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New Xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank ❑ Lift Pump Tank/Siphon Chamber Li Li Li ❑ L1 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 i nature: No Stamps) MP/MPRSW No.: Business Phone Number: n Ir 7 A65' Plumber's Ad ress( treet, i tate,Zip Code): Name of 01 ft G✓ , VIII SOIL ES RM TIO Cert''ed Soil Tester 4( flame CST# C I DDRESS tre ,City, tat ,Zip Code) Phone Number: ® 36sy CFO UNTY EPA NT USE'ONLY ❑ Disapproved Sa itary Permit Fee Groundwater 76� Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial ` ��11\\ S harge Feell p �Adverse Determination �� � V 8,0 /�+ X. COM ENTS/REA NS FOR DISAPPROVAL: bLI 7�)v4i�zr f'Il��cSClICJ 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 Location of Property S� ' Section , T 07t7 N - R W Township Mailing Address �[ '•� / � �� t-1 ` S J�y 7 �a Subdivision Name Lot Number Previous Owner of Property �, ��^��f` Total Size of Parcel � '� " ` 3 Date Parcel was Created ' Are all corners and lot lines identifiable? VI/ Yes No Is this property being developed for resale (s p ec house) ? Yee No Volume and Page Number --��_--- as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: ,^ 1. Warranty Dee yt�Gt �, ly ys / an ontract 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. f the deed description references tq a CertAfied/Surve y Ma the the Certified Surve Ma shall also be re uir ' XA < � PROPERTY OWNER CERTIFICATION I (We) ce&U6y tJw,t aU 6tatement6 on this 6oxm ate tiLue to the but o6 my (out) hnowtedge; that I (we) am (ate) the owneh.(6) o6 the PJ%opexty des Ch i.bed in tjUA in6o4mati.on 6oxm, by vchtue o6 a wauanty deed xecoxded in the 066ice o6 the County RegiA tet o 6 Deeds as Document No. ; and that I (we) p4e4 en tty own the p.4opoa ed 6.c to box the 6 ewa 006 a y6.tem (ox I (we) have obtained an easement, to xun with the above de6chdbed pxopenty, box the conat4ucti.on o6 6aid 6yatem, and the Game ha6 been duty tecoAded in the 066ice o 6 the County Reg,c6.teA o6 Deeds, a6 Document No. ) VOYc SIGNATURE 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLO DATE SIGNED DATE SIGNED 32504 t � .. t At' +s' TIM `�� '. made between cam Yd fr, �aaats in .,moll t dA►� �'..•..A.�,1$+ W i t s e e s s t b. That the said Greater tar. I out o sad (S2 �_�11srs•--..rsr,Pw,.-,� eeweys to Greate0 the following described rnal astab j, Bt-'Cr Y ;.fir tttete of Wisconsin- elftso To CHARLES E. USIHITE South 990 feet of West 220 feet`of lava Falk,rti,con,a e.. East 5/8 of East Half of Southwest Tana"a_ 3 + (E 1/2 SW 1/4) of Section 15, Towns4 � 4 7we to-mt_l wsaar Range /8 West. NbYe, M y E (This deed is given to`correet the elesi a former deed between the ��an o grantor,used ' pasties hereto, dated October 31, 1974, .P and recorded in the of$ce 0'the Register of,Deeds for St. Croix ' is County, Wis.oasin.'op November 6, 19749 in Book 517 on page 410 as ' s:j Document No. 324606). Tog— With W sed sing"the ditawsats igt/ And alpwaaaaas tberaa�ta be tossing or is atii wine appst►s� IR warrants that the title is flood, indeteas�M in tee "�. •laPi�and tkw aw clew of anceNdwanoan e:espt c Aw will warrant aid bfaw/b'saw. Esoested At__Riur �� 12e4 rir�r 'D�eceber ,tt0M, SIGNBD AND aliAtlD DI or r 'r y Gordon K. Callati, as pessoaal .K;,,_.,,representative of the Estate of George a . cea d4t,1 iw J : r fipetg,ee d '�:, natbeetirated this day of . 14__. r Title: Member state tiler of wisconste ar Other Party y Authorised gads: Sec. ; 706.06 STArR OF WISCONSIN ) ` Personally ease before me.this 12L dal of D�. s _ the she"named —Gordt?nK_ G — ' fiallati. 12essatsl,�.__ v"_t11:4 Estate of George A�__��n" to r known to be the person__ who executed the tore tf tehig tgstrtrsest and ackeww , d the same. F This instrument was drafted by ' Bread, L.?K •.:• CharIll >s. W {t .Attoraey at Law, •i~ 4 t' River Falls, Wisconsin 54022. Notwr Public The a"of witnesses is optional. vr°'• My Cowaiwir(>ayi,"Alli Namss of persons algwiy is any Capacity obosid be typed or pritnted below their sisntowg• 4 10"10 MTY D99111 UTt `AN AI ►i1RM ND. 1 - Ntl ��;_ z H a ST C - 105 r' r a SEPTIC TANK MAINTENANCE AGREEMENT H St . Croix County z ,D t7 OWNER/BUYER_ ��j��f�f7 T. I`0 itJ►'� fI14� /r � i�l�i(.� ,06 ROUTE/BOX NUMBER—,* Fire Number *aW_! sCITY/STATE ZIP _37}Voa3 PROPERTY LOCATION: �� , -s 34, Section l T N, R /X—W, Town of h rAt-yt St . Croix County , Subdivision Lot number o �� i�/ ?proper use and maintenance of our septic system could y P y u 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 m_ y 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. H 0 I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b 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 . t � 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 . of DUSTR PARTMENT'OF REPORT ON SOIL BORINGS AND SAFE fY & BUILDINGS INUSTRY, DIVISION "MA RE PERCOLATION TESTS (1151 P.O. BOX 7969 Ifl:)MAN RELATIONS \ / MADISON,W1537U7 (H63.090) & Chapter 145.045) (WATION: SECTION: �TOF�_NSI�1.IP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: NIFIIrE r)UNE/Y: OWNER'7RUYER'S NAME MAILING ADDRESS: fT_,_Cir04 r�/ 't�1, r ier c�,t�___�' v2 USE DATES OBSERVATIONS MADE �,/ NO.BEDRMS.=CdM—MF.RCIAI- DE SCRIPTION PROFILE DESCRIPTIONS: E LATION TESTS: ��/ 1'lltesirience ❑New MReplace IIATING:S=Site suitable for system U=Site unsuitable for system - — ---- )NV NTIONl�L: MOU D: IN-GROU D-PRESSURE SYSTEM-IN-FII-L HOLDING TA K: RECOMMENDED SYSTEM:(optional) i_L!S DU12S_CJU I C�S LU EIS CCU D S [✓ 1 >. e� C��'x�o I Percolation Tests are NOT required DESIGN RATE: [Floodplain,any portion of the tested area is in the ender s_H63.09(5)(b),indicate: ��/� indicate Floodplain elevation: A��� PROFILE DESCRIPTIONS —fi��� 1 4& "JUMI M)HING ER TOIL ELEVATION PTH TO GR UNDWATER-INCHES CHARACTER OF SOIL,W11 Hrtf HICKNESS, COLOR, TEXT RE-, AND DEPTH JUMI3ER DEPTH IN, OBSE(�VEU E GHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) � /P' Dk n S, y r �� r ✓ B-/ p1 ! �r on AP/ /?1st . r c�/ io" /rratry s r w 9 � g_2 s��-���—' B_ 9 .G /d' '0& rd r y/r j�n S:/ 5 -/her, /, DK en S•/� /oT 7 Nil 5,'/ '"/9 r i // " rl e•.v y s// zo B- ! g_d! ''µ �sl 6�Qr _�y ir1g��;n o.��sJ�t�1_Ltl—L�1�c.�?fJ,�o•��._ PERCOLATION TESTS TFST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES Nl1MBER INCHES AFTERSWELLING INTERVAL-MIN. p RIOD t PERI D 2 P R PER INCH i h T- r oo ih 1.JA r ,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- ,,nlal 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 d land slope. SYSTEM ELEVATION 9_S_ Se-a/e ".:,s ) ' is, glee• A Bn'1 �y o90/'. 37r P'P�r .1 eX z/ -A X11eC/ I r,1 -�'1/nce1 des f� ma rke,*0 4y T *q L t u/7Ir 11C. U'D S c. p�3 4,:aanW c/r v. loo t-are E] learv/ crk hole, 5-7 I # , ,ty' ❑ (o n hors o n /Y. If 1,1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. JAMF (print TESTS WERE COMPLETED ON: 2 - CERTIF CATION NUMBER: PHONE NUMB FR(uptiundl): DISTRIBUTION: Orullnal and rrne copy to Local Authority,Property Owner and Soil Tester. rll 1111 SRD-6395 (R.02182) - OVER - NL is u7 �E i O h`J 70•/'e Y�� )AVE FOGERTY PLUMBING Licensed Perk Tester & Plumber #3233 #3289 Fogerty Heights Road ROBERTS, WISCONSIN 54023 I X Phone 749-3656 HoRs� "ZZI . \115.; i n/ r r f � ,I I, \ I r pe /. o /+AC iMlu�AfioH 6tyor 2, 1 71p / X31/,5-4e/ p,�e ?Lo /f 117 12 • X wfLC PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER 2g' FROM DOOR. —7 WINDOW OR FRESH 12"MIU. I AIR INTAKE GRADE I I y"MIN. CONDUIT Ie"MIN. ---------- PROVIDE lAll-.ET � AIRTIGHT SEAL II v APPROVED JOINT A III APPROVED JOINTS W/C.I. PIPE. I I)I W/C.=. PIPE EXTENDIAIG 3' I Ill ALARM EXTENOIIJG 3' ONTO SOLID SC:;. B I I ONTO SOLID SOIL DF I I I I oN c I I I PUMP—1 --� All � OFF D CONCRETE BLOCK RISER EXIT PERMITTED ONLJ IF TANK MANUFACTURCR HAS SUCH APPROVAL SPECIFICATIOUS SEPTIC AMC) DOSE TANKS MANUFACTURER: GiJPCkS NUMBER OF DOSES: z PER DAy TAWK 51ZE : - GALLONS DOSE VOLUME ALARM MANUFACTURER: INCLUV!&!:, ZAC!tFLOW: 3o GALLONS MODEL NUMBER: -61 k' CAPACITIES: A= -797 INCHES OR 6./�_ GALLONS SWITCH TYPE: JB INCHES OR -3z GALLONS PUMP MANUFACTURER: Zorn/mot /8y{//inch C=�IMCHES OR 72 Z GALLOWS MODEL NUMBER: -"s3 D- INCHES OR GALLONS SWITCH TYPE: NOTE: PUMP AND ALARM ARE TO BE PUMP DISCHARC&E RATE 3y GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEKEMC.9 Dt91 wrEA! PUMP OFF ARID DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE✓. . . . . . . . , . . "�-�• FEET + ��D FEET OF FORCE MAIN X 3- /oorr.FRICTIOU FACTOR.. FEET TOTAL DYNAMIC. HEAD = /•9 FEET INTERNAL RIMEWSIOMS OF TANK: LEN&TH ;WIDTH Zz ;LIQUID DEPTH y� SIGNED: LICEMSE NUMBER: DATE:.i111Z,;' -117- TDH HEAD CAPACITY CURVE LU W "L 30 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE n EFFLUENT AND DEWATERING 95` SERIES 53-55-57-59 97 137-139 163 165 =T M ,AL LTRS GAL LTRS CAL LTRS GAL LTRS C"?_ 28 _ -----� r 152 a? 163 5 248 104 394 fit 231 " 231 �� EFFLUENT AND DEWATERING 3 os ,ZS sr 21s s 300 231 231 26 15, 4.57 19 72 43 163 64 242 �0 227 i 227 .5 SEWAGE AND DEWATERING j} 6.10 zi 104 36 136 223 ;o 227 \ 5+ 762 - 8 30 57 216 223 80 � ? 9.14 55 206 :5 220 24----G V .\ 12.19 46 172 206 \ 50 15.24 33 125 •1 191 75 \ i;0 18.29 15 57 43 161 22 `% -70 21.34 _ 30 114 70 \ 80 2438 14 53 MODEL\\ MODEL Lock vawe 19' 24.5' 26 66 97 20- 163 \ 1165 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE \ \ SEWAGE AND DEWATERING \, \ SERIES 267 268 282 284 293 18 \ \ FT M C.AL LTRS GTLLTIR S GALL LTRS GAL LTRS GAL LTRS \ ; 5 152 10,8 408 6 t3 4 92 ,.8q 681 55 10 3,05 30 227 2 273 9 360 15t� 598 4.57 .:.0 7613' 163 6: 238 :3 511 _.50 \ 80 6.10 __ 8. 30 3 125 10 401 Z5 7.62 - — 7 288 14 \ 30 9,4 4 163 7 292 A _- _. --- -- --- 45 \ 45, 10.67 _ .60 227 \ ; 40 12.19 -- — 46 174 \ 45 13.72 ?9. 106 -- 12 40 - — -- - - \ 5 1524 1 45 \ MODEL Lock vewe: e' 21 26 3s 53' 10 3a - I 293 \ � 30 \ � MODELS 8 25 137 139 6 20 •� .\ MODEL 15 4 ' 284 MODEL MODEL 10 268 8 282 2 I\ 5 53, 55, MODEL 2MODEL 57, 59 97 267 X1.5. GAL& 10 20 ' 30 40 `50 6Q I 70 80 90 100 10 i20 ,130 140 150 160 '170 180 190 LITERS 80 160 240 320 400 480 560 640 650 FLOW PER MINUTE Z Zj52rZZ11-F O. Old Millers Lane Manufacturers of. . . TA9. ILoulsville,P.O. Box 16347 Kentucky 40216 (502) 778-2731 `QUA!/TY PUMPS j%vCF /939 �� 8 w r , I w, rl i ti.. y e r \ . DEPARTMENT OF INDUSTRY, INSPECTION.REPORT FOR V � �OyD"��SAFETY&BUILDINGS LABOR&HUMAN RELATIONS �oJi PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 �./0� /, BUREAU OF PLUMBING � MADISQN,WI 53707 1_h(/�' I Gv`!"� 0 O� CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: N / w / �1�C( 1,� ❑Holding Tank El In-Ground Pressure ❑Mound (lf assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: BENCH MARK(lUmanent reference P-0 DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT ELEV. Name n/PIu tuber. MP/MPRSW No.. counry Sanitary Permit Number: >� SEPTIC NK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV,. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO I ❑YES ❑NO BEDDING: VENT CIA.: VENT MATL HIGH WATER ROAD: PROPERTY WELL BUILDING. JVENTTOFRESH' ALARM. LINE. AIR INLET. ❑YES ❑NO ❑YES LINO EM DOSING CHAMBER: MANUFACTURER IY E ONO G. LIQUID CAPACI TV PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. S OYES ENO EYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN:LINE AIR INLET PUMP ON AND OFF) OYES ONO SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing 'LENGrH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until I..g the soil is dry enough to continue.) CONVENTIONAL SYSTEM: ® r� WIDTH LENGTH NO.OF DISTR.PIPE SPACING COVER INSIDE DIA. -PITS LIQUID ' TRENCHES MATERIAL: . DEPTH- eF, 7a a I FILL DEPTH j)S T H I .PIPE DISTR PIPE DISTR.PIPE. MATERIAL. NO.DISTH -a PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER EL EV.INLF f ELEV.ENU PIPES LINE. AIR INLET: F y� MOUND SYSTEM: _ Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER ITEXTURE PERMANENT MARKERS JOBSERVATION WELLS DYES ❑NO DYES ❑NO DEPTH OVERFRENCH BED DEPTH OVER TRENCH.BEL) DEPTH OF TOPSOIL SODDED SEEDED MULCHED. CENTER EDGES 1:1 YES ❑NO 1:1 YES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: F E ^,WIDTH LENGTH NQ OF LATERAL SPACIN G. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER TRENCHES- MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR IDISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING -07MM,F m'T.ELEV_ ELEV. DIA. ELEV.. PIPES DIA_: s F`HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES NO 1:1 YES ❑NO COMMENTS: JPERMANENT MARKERS: JOBSERVATION WELLS ::ANN PROPERTY WELL: BUILDING LINE: ❑YES ❑NO ❑YES ❑NO Sketch System on Retain in county file for audit. Reverse Side. E. TITL EDILHR SBD 6710 (R.01/82) 7�� DEPARTMENT,OF APPLICATION SAFETY&BUILDINGS INDUSTRY, FOR SANITARY , DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,WI 53707 Attach plans for the system on paper not less than 8%x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: s X7 V Property Loc tion: City,Village or Township. County: /T,79 NCR E (or)eV Gtf T' Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or La?dmark: State Plan I.D.Number: /-Z (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1V1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY /goo HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER 5-0 MANUFACTURER: ° EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED(Square feet): ❑ New ER"Replacement ❑ Experimental 2Seepage Bed ❑ Seepage Pit / ❑ Alternative (specify) ❑ Seepage Trench Witteer�Supply: Owner's Name as Listed on Soil Test Report(If other than present owner): LJ Private ❑ Joint Cl Public I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature: MP/MPRSW No.: Phone Number: Id Plumber's Addre x Name of Design ! I COUNTY/DEPARTMENT USE ONLY Sigpelture of Issuing Agent Fee: G0 Date: Sanitary Permit Number: • '} APPROVED I OL ❑ DISAPPROVED CQZ 19 Reason for Disapproval: Alternate course(s)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County,Canary-Bureau of Plumbing,Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398(R.07/81) f e . r L INSTRUCTIONS FOR COMhETING FORM 1-15.- SCD - 6395 To be a complete and accurate soil test,your relrort must inciUde. 1. Complete legal description; 2. The use section must clearly indurate whether this is a residence or commercial pro' ect; - 3- MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; S: Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE use the abbreviations shown here for writing profile descriptions acid 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 i[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 yo'trr'current address and your certification number; 12. Make legible, copies and distribute as required= ALL SOIL TESTS MUST BE FILED WITH THE LOS AL AUTHORITY WITHIN 30 DAYS OF C ViPLETION. ABBREVIATIONS FOIE CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st —r Stone (over 10".) RR Bedrock cob Cobble (3- 10") SS — Sandstone gr — Gravel (under 3„) LS — Limestone *s — Sand HGVV — High Groundwater c;s - Coarse Sand Per(, - Percolation Rate rrre,l:s — Medium Sand VNell Fine Sand Bldg Building is Loamy Sand xj,- Qwafer.,char) ,l Sandy Loam. < ..- Less Than ;t I Leant Bn .__ 'Brovvn *sil -- Silt Loam BI _.._ Brack si - Stilt. Gy — Gray 'cl -- Clay Loam Y — Yellow sc€ - Sandy Clay Loans R — Red 1c3 S41 ty Clay-Loam mot Mottles t_.... . sc .. Sandy Clay Wnr vvith r sic -- Silty Clay fff - few, line,faint c _ -y <-c c;c arraorr r oi3rS*, _ .. - ... pt _ Peal ITIM — M y, cn drum m Muck -d -- distinct is - prominent _- r: HWL — High water level, Six general soil textures surface water for liquid waste disposal BM .— Bench Mark VRP'- Vertical Referericc Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. Thr;county or the Department pray request verification of this soil test in the field prior to pees-nit issuance. A complete set of plraras for the private sewage systems and a permit application must be submitted to the appropriate local authority in order to obtain a permit The sanitary permit must be obtained and posters pt ior to tkac start of arty eoaastructiors. A INDUSTRY,E�urOF REPORT ON SOIL BORINGS P.O.`AND sAFE7Y'& B DIIVISION LABOR AND PERCOLATION ,TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1) &Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: sE /�iv�/a s- /TT N/RIFE (o — COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: T 6.,X rre Vie. o z USE I DATES OBSERVATIONS MADE �.�,// NO.BEDRMS.: COMMERCIAL DESCRIPTION: ,��,// PROFILE DE CRIPTIONS: PE O A ION TESTS: ZeResidence New U?Replace y � �-zp rZ RATING:S=Site suitable for system U=Site unsuitable for system CONV�NTIO❑NAL:IMOU D:�� IN-GROIS FD URE: SYSTEM-IN-FILLHO❑LDS TANK:RECOMMENDED SYSTEM (optional) �,X,D r,U/7SS UU SS Q S U S rLJJtU S Al 1GOWAIX'M-41 C 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 BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXT RE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) l/ BJ .S'1' /1 Qk n S. W/,#�` /.7 ea O B- 9:y,1 on t /v/ 41 .. gu Sh / w / to" hectvyss wy . B-3 9 �3.4 N ] 9 /DN ©K fd, iY/�'Bn S�/ `��9 t'� 9��hot,vy S/, "o m m ii ak 6n s%/� Av' -Bn S:/ w�9 r //° v 011 B- B- f ,II PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- Alan Zo 3 P- P- Z P L G ! w P- 1.41 . , P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION � Iin yo € { � 4 �_ �-'�rtcc rj' i i x LI w tNE , : , € a E f E € I , , 3 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. FAS.rint): TESTS WERE COMPLETED ON: CERTIF CATION NUMBER: PHONE NUMBER(optional): N DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) OVER — 4 � I 1 • I i • •-�i�i co c� �� •,� 4°�o"a�''� a �CA 46 49 lei lam/� • ] 1 • . a •1 s,i ��K�sfiti�� I q7 XV� (xI x o) s��►�oz k ' 1 � %n S�arliP / �r_SO Wisconsin Department of Health and Social Servicos Plb. #67 370 Division of Health S"ASE SEPTIC TANK PERMIT APPLICATION (�62 -��� S-E NElS& TYPE or, USE BLACK INK E S lei 3 S 3 - 0 J l A. OWNER OF PROPERTY C S�P 0� �/y S(�tJ /tf. IJc�a' Diva Name Address (Streets City, Zip Code) �� /3/!�/- a 7 B. LOCATION OF PROPERTY WHrRE SYSTEM WILL BE CONSTRUCTED ALTERED OR,EXT,ENDED COUNTY ( Check One: a•°'/G CITY VILLAGE LEGAL DESCRIPTION TGWNSx 1 J ✓ S � `St C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO _ _ PERMIT NUMBER D. SEPTIC TANK CAPACITY /D Q C) Gallons NEW INSTALLATION _,K_ REPLACEMENT ADDITION MATERIALS: Prefab Concrete Poured in Place Steel Other �+ NUMBER OF TANKS TO BE IYSTALLEDs (9&e E. TYPE OF OCCUPANCY / Cheek Ones Ono or Two Family Residence -Z— Commercial Industrial Other Specify Number of Persons to be Accommodated Number of Bedrooms CZ F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES-AL NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) G. MASTER PLUMBER MAKING INSTALLATION Name: "P U.j, 0-,�j 2)1 Address: '0/ 'License Numbers Signature of Applicants /'i �!!' r, MP RSW Address s ZA H. (To be Completed by Issuing Agen.;) Date of Application -7/ Fee Paid Permit Issued (dat �- Z Permit Number Agent (Name) �0 For: L 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 fomard application, the fee of $1.OU for each septic tanir and the third copy of the permit (canary) .o the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY :. DATE RECEIVED �- �� ? ACCEPTED BY RETURNED (Initials) D (Date) See Corres.) FEE RECEIVED I/ VALID. No. SG �G�O PERMIT N0, _ N /-7�,_ es or No ' REVIEWED BY APPROVED DATE (Initials) Yes or No COMPLETE OTHER SIDE Y SEPTIC TANK PERMIT N0. _1 yid REPORT ON SOIL PERCOLATION TEST AND SOIL BORINGS TO DIVISION OF HEALTH - PLLMBING SECTIdN P.O.Bux 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code P E R C O L A T I O N . T E S T Test Depth Character of Soil Hours Water Test Time min or Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to .. Next to Last o Fell let Wetted Overniatt in Minutes Last Period' Last Period Period One, Inch Example P - 0 36" Top Soil 10" Clay 26" 25 Yes or No 30 1 2 1 2 _Y2 60 Oct if" y RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption arse. in accord with H 62.20 Wis. Administrative Code. S 0 I L B O R I N G S - Minimum 36" Below Pro osed Abs? tion 5 stem Boring Total Depth Depth to Ground slater Depth to Bedrock Number Inches Observed Estimated Observedl Estimated Character of Soil with Thiokness in Inches Example B _ 0 7211 72" Black Top Soil 12"t Clay 18111 Sand 1811_t Gravel 24" Zo OF Zk RECORD DATA FROM MINII^M OF 3 BORE HOLES YPE OF OCCUPANCYs /� RESIDENCEs Number of Bedrooms OTHERS (Specify) 013�1� /71-DLL Number of Persons D WASTE GRINDERS Yes No Dishwashers Yes No Automatic Clothes Washers Yes �-No EFFLUENT DISPOSAL SYSTEMS NEW EXTENSION ADDITION REPLACEMENT , n � Tile Size NO.Lin.Feet Trench Width k Depth Q Number of Lines Seepage Beds Length Width Depth The Size -No. Lines fSeepage Pits Inside Diameter :, Liquid Depth ` Is the undersigned, hereby aerti-,y that the percolation tests reported or this form were made by me or under my super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. // NAM: ��.4 JJ ":l b'�� TITLE Type or Print)) REGISTRATION.NO. or MASTER PLUMBER -LICENSE NO. ADDRESS R / i�i 11E'R /L/�L6 S^ C�>!, 3 5'31P DATE SIGNATURE %7,_ -f�/ /- � ✓' ��''�