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HomeMy WebLinkAbout004-1031-60-001 St. Croix County Planning and Zoning Wednesday, January 25, 2006 at 3:02:45 PM Detail Sanitary Information Page 1 of I Computer 0041031-60.001 Sub/Plat: NA Section: 14 Parcel 14.28.15.212B Lot: 1 TNIRNG: T28N R15W Municipality: Cady, Town of CSM: Vol. 05 Pg. 1426 114114: NW 114 NE 114 Owner: De Gross, Peter 395 315th Street (fka Shady Lane) Wilson, WI 54027 State Permit: 79142 Issued: 05/0811986 POWTS Dispersal: Mound Permit: Replacement County Permit: 0 Installed: 0610411986 POWTS Detail: NA Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Reauirements Additional Notes Money Owed Mary Jenkins Yes Helgeson, Bennie $0.00 Tom Nelson Signed Off: Yes Maintenance Scheduled Pump Date-Pumped 1st Notification 2nd Notification 3rd Notification 61412006 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - NW NE, Section 14 DE GROSS PETER T28N-R15~ i Rt. 1 Wilson, WI 54021 Town of Cady I 5_8_ B. Helgeson San.Pe~it~)79142 Mound, Replacement r P pf ..i- Q. i 01/25/2006 02:56 PM Parcel 004-1031-60-001 PAGE 1 OF 1 Alt. Parcel 14.28.15.2128 004 - TOWN OF CADY ST. CROIX COUNTY, WISCONSIN Current ' X Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-owner O - SELIGER, RANDALL J RANDALL J SELIGER 395 315TH ST WILSON WI 54027 Districts: SC = School SP = Special Property Address(es): ' =Primary Type Dist # Description " 395 315TH ST SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 10.450 Plat: N/A-NOT AVAILABLE SEC 14 T28N R1 5W PART OF NW NE 10.45 A Block/Condo Bldg: LOT 1 CSM 5/1426 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 14-28N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1006/67 WD 07/23/1997 828/330 07/23/1997 808/555 07/23/1997 690/97 2005 SUMMARY Bill Fair Market Value: Assessed with: 106540 147,500 Last Changed: 09/07/2005 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 28,000 117,500 144,100 NO UNDEVELOPED G5 6.450 4,100 0 PRODUCTIVE FORST LANDS G6 2.000 6,000 0 6,000 NO Totals for 2005: General Property 10.450 38,100 117,500 155,600 Woodland 0.000 0 0 Totals for 2004: General Property 10.450 16,300 45,000 61,300 Woodland 0.000 0 p Lottery Credit: Claim Count: 1 Certification Date: 0411712001 Batch 511 Specials: Category Amount User Special Code Special Assessments Special Chargeess Delinquent Charges Total 0.00 TOO 1900 ►4$~`'~st, One Quarter ( ) of the Northeast One Quarter (NE4) of Section o ee`n (ll), Township Twenty-eig 28) North, Range Fifteen (15), Town of Cady, St. Croix County, Wisconsin described in Volume 5 of Certified Survey Maps on page 1h26 as Certified Survey No. 142 l , . 1..:* SAINT CROIX COUNTY CERTIFIED SURVEY MAP MAP BEARINGS ARE REFERENCED TO THE NORTH - SOUTH 4 L E G E N D LINE OF SECTION 149 T-28-N R-15-W. P.O.B. = POINT OF BEGINNING ASSUMED SEARING = H = 2 STORY HOUSE NORTH 00 00'00". p = 60p SPIKE & SHINER IN THE TOP OF A 12" DIAMETER X 620HIGH WOOD POST. 0 '4E.M FOOT. WEIGHT 1.13 POUNDS PER LINEAL SCALE IN FEET'1"s 150, jj~1PLATT ED LAN D lao~ 0 75' NORTH 4I CORNER OF SECTION 14 NORTH LINE OF N.E.4 OF N.E. CORNER OF SECT] PO.B,I T-28-N R-1 SECTION 14 14 T-28-N R-15-W . E r-. T COUNTY MONUMENT ST. INP~,p CPCROIX --00 9 M • • 25'4 i N' 29 ~8 49 E 747. /5', • 1908.88 CR714.15- : COUNTY CE $ ALUMINUM MONI MENT INPLACE. . p - QS 00 4559 030.90 SQUARE FEO W 10.45 ACRES INCLUD- ING TOWN ROAD RIGHT 4359 592.63 SQUARE FEET = 10.00 ACRES EXCLUD- U_ N_ P L_ A T_ T E D TOWN ROAD RIGHT OF WAY. LOT I • m °D LAN D 0 0 go 3815 u C3 Q*. Q BARN FILED M e E» JUN T 1984 M DES 0' CONNELL ~ 7/4.88 R.oar.r of c.•as / N -87"'22'40 -.W.. • •747.89. 8► C" k Cmy w • • ' ' Wboosla U N P L A T T E D L A N D L NORTH - SOUTH 4 LINE OF SECTION 14, T-28-N R-15-W APPROVED ~.`$tQw lUN 0 6 1984 Y N • s _ ST. CROIX CDumy x .COAVAEMENSIVE PARKS PLIW+WO 0 c AND zONNG COMMITME Z JSU SOUTH•s4SVORNER OF SECTION 149 T-28-N R-15-W ST. CROIX COUNTY MONUMENT SET N Volume 5 Page 11126 TIIA'IDIE•'. Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER dl~~S TOWNSHIP SEC. ~ T ~N-RW ADDRESS eC>U& I ST. CROIX COUNTY, WISCONSIN L~r Loo S'IOd 7 SUBDIVISION 4 LOT LOT SIZE ~ Q e(f , PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM J 1~ ?Ircr~ I t00.0Top 04- I ~eck. -iV ~ Cornet aa' 000 6rJ 7~o 641 PahNp f~-« C.,~aw~,~nec- INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ~ zrm _er Qc_ Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer CAL quid Capacity: /100 0 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from neares rRoad: Front, Side0 Rear, V 00 feet .From nearest property line Front,vSide10Rear, 0 00 feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: 4,04 squid Capacity: eo-' p Model Pump/Siphon Manufacturer: Pump Size Elevation of inlet: 91 Zr Bottom of tank elevation: Pump off switch elevation: Gallons per cycle Alarm Manufacturer: Switch Type: Number of feet from nearest property line: Front,C'Side, O Rear, 0 Ft. Number of feet from well: 9'7 ~p~ i Number of feet from building: 2;0 (Include distances on plot ~plan). SOIL ABSORPTION SYSTEM o4u off' 3s X fn9~ Bed: Trench: Width: 57 Len the -75 Number of Lines: "41 Area Built: Fill depth to top of pipe: e Number of feet from nearest property line: Front, Side, O Rear,0 Pt 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, 0 Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector 45 o, Dated: Z Plumber on job: e ~.3pl~ License Number: 3/84:mj DEPARTMENT 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 [NYgLTERNATIVE state Plan LD. Number: a'~~+°~5455 O Holding Tank O In-Ground Pressure U Mound INSPECTION DATE: NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: / J I?/.. Peter De Gross Rt. 1, Wilson, WI 54027 6 oREF. PT. ELEV.: EF. PT. ELE V.. BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. NW'I4 of the NE14 of Section 14, T28N-R15W, Town of Cady CST R Sanitary Permit Number: Name of Plumber: MP/MPRSW No.: Counry Bennie Hel eson 3215 St. Croix 79142 SEPTIC TANK/HOLDING TANK: MANUFACTURE : LIO ID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING OVER PROVIDED 9, PROVIDED /PD D / YES ONO ❑YES NO PROPERTY WELL I V BEDDING: VE NT DIA. HIGH WATER NUMBER OF ROAD: LIN : VENT MATI I ALARM FEET FROM YES ONO ❑YES ONO NEAREST DO 7 1. DOSING CHAMBER: AIL, - - A 1,7 j9 j< MANUFACTURER. BEDDING: I UID CAPACITY PU MODEL PUMP;SIPHON MANUF AC7UNEH gOVIDEDLABE pROVIDEDO ER YES ONO YES ONO YES ONO PUMP AND CONTROLS OPERATIONAL. NUMBER OF pHN)TY WELL ' BUILDI GI AIR NLET ( FFE E PER Y L FEET FROM 11 : PUMP ON AND OFF) RE ; (DIFFERENCE BETWEEN ❑YES ONO NEARESTIII - l l i DIAMF It M11AT E HIAL AN U M AH IN(i SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE F Nc, or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: N IU A LIQUID BED/TRENCH WIDTH-. LENGTH TRENCHES UISTH PIPE SPACING h1ATEHIAL, PIT rL DI aPITS DE NT PTH DIMENSIONS NUMBER OF PROPERTY WELL BUILDING V TO FRESH D ISTN RAVEL DEPTH FILL DEPTH UISTH. PIPF UISTH PIPE DISTR. PIPE MATERIAL NO LINE. AIR INLET: BELOW PIPES ABOVE COVER El EV INLF I ELEV. ENU PIPES FEET FROM 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑N PEHMANf NT MARKE H$ OBSERVATION WELLS OIL COVER TEXTURE a YES ❑NO O YES ONO "'LI MULCHED DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SOUDFD CENTER / EDGES A o S ~yy~~ YES ON O ❑YES. NO LJYES ONO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER 7EL LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE tJ BEDITRENCH ,7d TRENCHES DIMENSIONS / - I PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL F PEDIS FR UDISATR. PIPE UISTRIBUTION PIPE MATERIAL & MARKING ELQEV. DIAn ELEV(ELEVATION ANfl t'J .7v ~G /0~ Si s DISTRIBUTION AL IFT CORRESPONDS TO APPROVED INFORMATION E SPACING DRILLED CORRECTLY PLANS _YES El NO O YES ONO PROPERTY WELL: BUILDING: PERMANEN MARKERS OBSERVATION WELLS: NUMBER OF C O MMENTS: r FEET FROM YES ❑NO YES ❑NO NEARES : LI Oi~~ f Sketch System on Retain in county file for audit. Reverse Side. sIGNATURE nTLE DI LHR SBD 6710 (R. 01 /82) unsconsln APPLICATION FOR SANITARY PERMIT ~ DILHR (PLB 67) COUNTY ~ DEaRRTmenT of UNIFORM SANITARY PERMIT # - InDUSTRV, LRBOR & HUMRn RELRTIOnS / 9/ Al 11')L~ -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 OWNER MAILING ADDRESS Le,-- c 1-oS PROPERTY LOCATION CITY: U)1/4 f 1/4. S ILLAGE: LI& N, R K_kfor) W (rc LOT NUMBER IBLOCKNOMBER SUBDIVISI N NAME NEAREST ROAD, L E OR LANDMARK STATE PLAN I.D. NUMBER e-7-11 Al y0 SS TYP ~ig E OF BUILDING OR USE SERVED r n C 1 or 2 Family Number of Bedrooms: JE1 Public (Specify): 5/~ THIS PERMIT IS FOR A: ❑ New System Tank Replacement ❑ Repair f Replacement ❑ 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 Zo r) C-) v Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: a h 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 ~ d Lift Pump/Siphon Chamber v Manufacturer: MI-cl -r,,, C c 4 T~ PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED jSquare Feet): PROPOSED (Squ re Feet): C[ 43et sa I r9 re -k !34 sue/ & I- e S 0~r Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of lumber (Print): Signature: MP/MPRSW No.: Phone Number: t" 1274P 51a Plumber' Address: Name of signer: ! i t h « t°h/!/Y ,eras COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ~a~~ ❑ Owner Given Initial Approved Adverse Determination Reaso for D. app al Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 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 now 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. 3' z'y, cam, l APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractQ.V,("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 ,A)Section, T N - R W Township Mailing Address LV I L. SO S~U a? 7 Subdivision Name Lot Number Previous Owner of Property r Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being; developed for resale ( ec house) ? Yes ~ No Volume - Z-1 and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 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. PROPERTV OWNER CERTIFICATION I (We) eentijy that att atatement6 on th.i6 6onm ane true to the beat o6 my (ouh) knowtedge; that I (we) am (ahe) the owne-416) o6 the pnopenty deecAi.bed in thib -tnjonmatcon 6onm, by viAtue o6 a wann.anty deed seconded in the 066ice o6 the County Regi.6teA o6 Deed6 ad Document No. ,30 7 and that I (we) pke6ently own the phopoaed .6 to boa the e ewage poa a ydtem (on. 1 (we) have obtained an i"emen.t, to nun with the above ducAibed pnopehty, 6oA the eonbtAucti.on o6 aai.d byetem, and the eame ha6 been duty heco4ded in the 066ice o~ the County Reg-i-eten. o6 Deed6, as Document No. 3 q. 0, . TGN~Ti1RE~O~ OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) aA17i 3ZGM D DATE SiGMED h t kkliZ 111 ?2.. 5. - Safety and Buildings Division -w~ PLAN APPROVAL Bureau of Plumbing DILHR P.o Box 7%9 ❑ General Plumbing Plans Madison, WI 53707 Private Sewage Plans Telephone: (608)266-3815 } OFFICE USE QN&. Plan Identificatio(I (y'P Gallbrts Perf32~}+r; F iw; R= P•C't7tiOR PUS t4tA4~±C~ Project Name Proje~~ct~~ Location - Street No. or Legal Description County ❑ City ❑ Village Town of: I-IS7. C z a t The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan approval must be obtained. FOR PRIVATE SEWAGE PLANS: ~j This approval will expire two years from th€ a approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. Comments: By: James Sargent Bureau Director If Questions Plans Approved By: D qllql~ Contact cc: WS ❑ DPS ❑ H&R & Rec. San. ection County ❑ Local PI El Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other 0r HYDR-O-MRTIC SECT ~ w • . PUMPS DIMENSIONAL DRA & PERFORMANCE DATA MODEL: SP40A SUBMERSIBLE SEWAGE'PUMP-MAX. SOLIDS 11/4" SPHERE 1760 Rp*- It HEAD r - --r- ' _ - - i ' a/' ' . O. 4< z o HP MOTORo IN FT. ` 24 4 } - - 22 44 t t__. quo - j 1 l r - T 20 qC/j 16 - - - 14 i 12 10 I FULL LOAD AMPS AT1 (6115V. - - - e T 230 V 4.7 - -t • 6 FULL LOAD r + ! SAT30230V. AMP - - - fi - } I a 2:72, AT 460 V. 1.36 2 t 00 20 40 60 80 100 120 140 160 180 U-S. GALLONS PER MINUTE 4 MODEL: SP40A pfor% ? 4 6Qr 16 5515116 if-- 5"'8 ~ O • o O ~ p .ir 4 I 11'/4 ( 5' /8 2 STD. PIPE -t OWN RZ IPETE2 De-6ROVS 45/16 HELGESON TRUCKING, INC. Spring Valley, Wisconsin 54767 JUL 11 199 NOTE: CASTING DIM. MAY VARYs x a' l k r. • lo~ ` I-e 4 t-- De.6 rosy y a A NE f ov-rer © ca(- ;)KY be G~ -41 SCQI~ 1" = ,S'O f a~ sy5leni f/V, la-2 8 Z~ r L s Vim,. t- tY 6 HELGESON TRUCIQNC;R A Spring VbRey, Wi mnsi~ JUL I I , INifMP t AMDER CRASS SECTIM AMC) SPECIFICAT v ar VENT CAP i'WEATHER, PROOF , 4 = . JUIXTIOU BOX MAIN LS vwb*. I rMlw. Ow rResa IIVTAKC F . 1 GRADE Alt 00 COQoUIT ID'MII►!. LE: l tA)T PROVIDE I AIRTIGN SEAL I ( ( ~ / I II -7 v APVKGVEU JOIN A r I III APPROVLD J61aft', WI C.I. PIPE I I I 4C.I. PIPE , EXTEIJDIIIJG 3' I (I I ALARM EXTEUDIIJI. OUTO S(JLID .[.Il. B ~~%j = I I ONtO SOLID 10 ' r PU MP, - - OFF COAICRETE BLOCK RISER EXIT PERMITTED GA1L4 IF TANK MAIJUFACTURQR• H^S SUCH APPRDVAL t SPECIFICATIOUS iEPTIC AMID h, 1 (41 gAC_k )OSE TANKS MAWUFACTURER: AIUMBER OF DOSES: r hEK Dmf TAWK ',IZE: ;Z S:0 C7ALLOAJS DOSE VOLUME: _.._A` k1l GALLOA)S ALARM MAIJUFACTURER: c r f 1 rot. CAPACITIES: A- G' MICHES OR ~AC LOA.' MOVEL WUMBER: B=~IMCHES OR GALLON SWITCH TYPE: ll[Pr (f lr" ©r C3 l°"c IMWFS OR 6 S- IPALL P W MAKA)FACTURER: ~►,~M''-llC~ - N C D- ~d IAJCHES OR 40L/ AALL MODEL AIUMDER: -SJ TV A NOTE: PUMP AIJD ALARM ARE TO DE / A~1 IU5TALLE0 OU SEPARATE CIRCUITS 41 SWITCH TAPE: ~ty F/onf y ur~ PUMP DISCHARGE RATE 31r GPM 1~Y VERTKAL DIFFERENCE DETWEEIJ PUMP OFF AA)O OISTRIbUTIGM PIPE..FEET 144"I"M NETWORK SUPPLY PRESSURE . . , FEET y4°°~ 101 MET Of FORCE /''MAIM X 11~ F%j~ FEET G~SO pp rtFRICTIOU FACTOR,._ TOTAL OyAIAMIC HLAD - 1114.ag FLET ~Q ~Vt a< , IOAIt OF TAUK: LEIJC,TH ;WIDTH, -;LIQUIO OtrTM LICEAISE UUM69R: s.1G2L~ 4r1~IE 4'` :*m ',&alpA ttm 3s ~ Y MLL NOS3E)'IaH 1 q ` h) k~ . v ~J J 41101411 I - N u}IN O,.IOj PuI - -ADIOW}p VIOH :Pau6iS V: S f.i.. _ a d Ino o-1 sdld uo nqujgf4 , r;` a Ooa W3 0l IxMI y 09 Plo"s *ION JSDI "Id 'r00lnaijh,d j :)Ad N 4PO "6409 ro POWs" so" • 4 OdId Ud Ooloajwd doh 1u~ A O J • yp. h Ali j 7T; y* y Strew, M Ray, Or T ~ , rAn L.. Mtd%m SAAB ..e Q,~ Rr . Topsoil b ` s. 3 0 i X Slurp a1" a ' bad Of ' 2 %Z Foeco Main PIoAd; ; . P Aggregate From Pump Layer D Ft. i Cross Section Of A Mound System Using A Bed For The Absorption Area e r: G r0s s 1 y tot _S A Ft. N . Sioned._ - R r_ f License Number : CiP _ I \ ~l ! 4 Date. a,. Pt" a(~ Ft. Force Main w ~r Observation Pipe--, 1--~----- K , ' y A J t r.. 71 stribution Bad Of 2 ~y, ¢r Pipe Aggregate t_ 'g Permanent W~rkets (~bsarvrttion Pipe NH+4 tit Mound Using A Bed For The Absorption Anti . HELGE§OIL '1'ftUCII' t Spring Valley, ~1ViscoAAA umsconwn SANITARY PERMIT 'Z~DILHR County GROUNDWATER SURCHARGE nousrrH,u+e~s►.~rnnaeumons Sanitary Permit No. ,7j1_y;L On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com- monly 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 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that 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. 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- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. Ground o_w Signature of Issuing~go Groundwater Fee: Date: WISco iWa buried tr8syteure DILHR SBD• 9 (K/05/#f 1 State' Of Wisconsin ` Department of Industry, Labor and Human Relations i ` SAFETY & BUILDINGS DIVISION October 3, 198+4 Bureau of P l umbi lg 201 East Washington Ave. P.O. Box 7969 44adison, Wisconsin 53707 Mir. Peter De Gross Route 1 Wilson, W1 54027 Petition No. 34-05455-P Dear qtr. De Gross: Re: Peter Be Gross - Re s i dene e Private Sewage System lIW OME,14,Z8,15W - Town of Cady, St. Croix County, W1 The petition for at variance requested to section ILHR 83.23 (1) (d) of the Wisconsin Administrative Code was considered on Sept+maber 19, 1984. The petition has been conditionally approved, the condition being that in the event of failure, the mound system shall be replaced with a holding tank or other off-lot systems. Tho- rule requires that a mound system have a minima 24 inches of suitable natural sai 1. The variance requested was to install a replacement end system on a site with 14 inches of suitable natural soil. All of the data and statements submitted on behalf of the petitioner were considered. This variance is specific to the subject petition and cannot be used for any additional modifications. Sinctrely, James Quinlan, Chief Section of Private Sewage JQ:PEP:jn cc; Lamy Jaanske, Private Sewage Consultant - District 6, Chippewa falls rold C. Barber, Zoning Administrator St. Croix County vuemie Helgeson DILHRSBD-6423 (N. 04/81) r 0 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND P.O. BOX 76 HUMAN R,-LATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: V) '/404 ! /%O/R 1S cor) W ccd V AJ ~ COUNTY: OW ER'S &WA0*R-'%:W"E: MAILING ADDRESS: t'~ P U.. Q Wilson 0 USE DATES OBSERVATIONS MADE X~ NO. BEDRMS.: COMMER IAL DESCRIPTION: PROFI DES RIPTIONS: PERCOLATION TESTS: IalResidence J ❑ New Replace / ;4 g ~ J " /~r RATING: S= Site suitable for system U= Site unsuitable for system COa STI~ . M plS. ou IN -GROUND S ESSu RE: SYSTEM-I RU 0S HOLDING T~ :RECOMMENDED SYSTEM: (optional) S, L 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 BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- r 1j1.0 y3, / e5h.e, a a 61 S ►i s , 6 u 8n S, , 3 _ t g., ~ J'jr B- 3.® 9 0 y S. / TS , _5-4 f 8n _<,,/A9 F,0 ~t>T / D Rd $h,SL U-4- B-3 d S ( p~ el S,/ 125 & s; sue, s;/ ~Iaf ~ g B1 s, / 7.s a<tBA S,/ B- g 2-~ B d t~ f I -8 y Bra SJ~ b Biz ~~FF /'~O o B- Cp 4/401 ~O 0 3, 3" . (o B/ St~ 7S . Lf ~Sh v` , ~D Mo f " o S G PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIO7D~2 PER1003 PER INCH P- 2 P- - 1 P- v1 f L ( / 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. SYSTEM ELEVATION r I PROFILE DESCRIPTIONS 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- 7 ,1, fv 'Plot- A" B- L B- 3 881 S,~l ~s . S ~f 4. S'"j A".') /?C/,&.1 F S k 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 Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. 'E jrint : TESTS WERE COMPLETED ON: ` d ele SS: CERTIFICATION NUMBER: PHONE NUMBER (optional): Q 722 ~0_ 5- CST SI AT RE: Original and one copy to Local Authority, Property Owner and Soil Tester. D5 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - BD - 6395 To be a complete and accurate soil 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; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9, Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as 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 cob Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate med s - Medium Sand W Well fs - Fine Sand Bldg - Building Is - Loamy Sand > - Greater Than sl - Sandy Loam < - Less Than *1 - Loam Bn - Brown *sil - Silt Loam BI - Black si - Silt: Gy - Gray *cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc- Sandy Clay wl with sic - Silty Clay fff few, fine, faint Ic Clay cc - common, coarse pt - Pe, r mm - Many, medium n, d a p HWL - High water level, Six general soil textures surface water for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point i. TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county orthe Department may request veriiication of this soil test in the field prior to permit: issuance. A complete set of plans for the private system and a permi' lication must he submitted to the appropriate local authority in order to t' ~rs7tit. The sanit nit must be obtained and posted prior to the start of any construhtki'ti`. N i T C 105 j SEPTIC TAX% SAINTENAN01 '+AG*1kV NT . r . St. Crai% County W*R J o ROUTE/BOX NUKARK / > Sire NuAbo:, CITY/STATE ZiP~ t~. UV PROPERTY LOCATION: Section T U It Town of Cad St Croix Comity, n Subdivision Lot number' Improper use and maintenance of your septb; system could result le its prewatur.e"failure to handle wastes. Pr#.per maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank kumper. What you put into the system can affect the function of the septic tank as a treat- went stage in the waste disposal system. ; .p~ St. Crolx.County residents may be eligible to receive a grant for ~ a maximum of 60% of the cost of replacement of a failing eyateslo which-was in operation prior to Jul 78. St. Croix County, accepted this program in August of r0~ith the requirement that owners of all new systems agree to ke 't heir systems properly maintained. r'r The property owner agrees to submit to 8t. 'Croix County Zoning a certification form, signed by the owner an0 by, a master. plumber. Journeyman plumber, restricted plumber or a li'cetlsed pumper veri- fying that (1) the on-site wastewater disposal system isi-in propnlt operating condition and (2) after inspection and pumping (if nec' essary), the septictank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance w14= the standards set forth, herein, as set by the Wisconsin.Uepartt meat of Natural Resources. Certification form must be c6oplet mad returned to the St. Croix County tuning OffkVe within„30 da of the three year expiration date. SIGNED 1 z _ DATE ,r ~ 4.izxouaty 'Zoning Office ' *40"14, Wt 54015 38► 39 or 71 25-8363 r torte and retura. to above address. 4ir f k i i ` f t : F 6 , - F-T State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION October 3. 1994 Bureau of Piing 201 East Washington Ave. A P.O. an 7969 Madiso ns Wisconsin $3107 10 Mr. Petatr 0* Grass joy; s19o ♦ Roots iii Ism, W1 5W7 Petition go. 84-05,465-P z t Sear 14r. Ue Gross: Re. Pater Be Gross - ltesiaoace Private Sm age System MW „bE 14>r 28915W TOM of Cady, it. Croix Sys W1 They petition for a variance re"oSted to section LMR 83.23 (1) {d} of the Wisconsin Administrative Code was considered an September 19s 1984. The petition has been conditionally approved. The edition being that in the event of failures the aid system shall be replaced with a holding tank or other off-lot syster . The rule requires that a sound system have a sliniam 24 inches of suitable natural wi 1. The variance requested was to install a r*plac t *Duad system on a sito with 14 ids of suitable natural soi 1. All of the data and statements submitted on behalf of the petitioner considered. This variance is specific to t.lil~e subject petition and ca not be used for any additional mWificatlons. Sincerelys James Quislans Chief Section at Private Serge cc Leroy 111ensko, Private Sewage Consultant - District 6, Chippewa falls wMarold C. Barber, Zoning Administrator - t. Croix County Bowie Ole19esan D I L H R S B D-6423 (N. 04/81) Safety and Buildings Division DI LHR PLAN APPROVAL Bureau of Plumbing P.O Box 7%9 ~o .a .Aa ❑ General Plumbing Plans Madison, WI 53707 x Private Sewage Plans Telephone: (608)266-3815 OFFICE USE ONIY Plan ki6stification Gallons Per Day .w..._____ ._._.,m. PRIORITY REVtFW ONEY~ Plan Review Petition, For Moel cation Project Name Project Location - Street No. or Legal Description County ❑ City ❑ Village Town of: The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan approval must be obtained. !tete FOR PRIVATE SEWAGE PLANS: This aPProval will exPire two Years from approved below or if a sanitary Permit is obtained, it will expire the day the initial sanitary permit expires. Comments: By: C James Sargent Bureau Director If Questions Plans Approved By: tr f, f D 7ep Contact cc: OWS ❑ DPS J~ ❑ H&R & Rec. San. ection County ❑ Local PI - ❑ Facilities Need Analysis Section ❑ L)W-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other SBD 6678 (R. 08/83) (Plb 100a) (Wis Stats. S. 145.02) 143 STATE OF WISCONSIN DILHR.3 DDO Detach And Return Upper DIVISION OF SAFETY & BUILDINGS BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 141 Portion Of This Form With Any Return Correspondence P.O. BOX 7969 MADISON, W153707 608-266-3815 8 DATE: PROJECT. A O tles~~~ irucki ray, Trc U i r' G PLAN ID. - - - - - - - DETACH HERE - - - - - - - - ~stx v i 5'' p PROJECT NAME <«~rie2 PLAN ID... This is to acknowledge receipt of your plans and specifications for the above-indicated project. Preliminary review indicates the required fee is $1 i 1J. 00, Fee Received is X Plan accepted for review. ❑ Underpayment- Please submit additional fee. Plans will be held in abeyance. ❑ Plans being returned. ❑ Overpayment-Refund forthcoming. ❑ Additional information required. SEE BELOW. ❑ No fee has been remitted. Plans will be held in abeyance. 1. Plan Submission ❑ Soil boring and percolation test data on 115 completed ❑ Additional information shall be submitted in duplicate unless by Certified Soil Tester. (1 copy) specifically noted. ❑ Petition For Modification signed by county, owner and ❑ Plans not clear, legible or permanent. notarized. (1 copy) ❑ All information submitted shall be signed, dated and sealed or ❑ Complete data relative to anticipated use of building. stamped in accord with Section ILHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required. (1 copy) Administrative Code. ❑ Affidavit enclosed.- ❑ Condominium declaration. (1 copy) ❑ Plot plan showing location of land parcel (distance from nearest road intersection, etc.), lot size and all distances from IV. Holding Tanks private sewage system to buildings, lot lines, well, water- ❑ Holding tank profile showing vent, manhole, alarm, course, swimming pools, water service piping, all weather ser- and manufacturer if state approved. Complete vice road, etc. Show benchmark with permanent elevation. construction, details if site constructed. Holding tank agreement signed by owner and local ll. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed). ❑ Application for Use of an Alternative System signed by owner ❑ Reason for installing holding tank. Statement from and notarized. (1 copy) county or soil boring and percolation test data on 115 completed by CST, showing that a soil absorption system ❑ County cnsite required. (1 copy) El Design calculations. be installed on the land parcel. . ❑ Soil boring and percolation test data on 115 completed by cannot Certified Soil Tester. (1 copy) ❑ Affidavit for all-weather service road (enclosed). ❑ Cross section of system. ❑ Pipe lateral layout. ❑ Plan view of system. V. Dosing Information Calculations for total dynamic head and gallons ❑ Verification fo Exception Status Form by county. (1 copy) pumped per cycle. III. Private Sewage Systems ❑ Size, length and depth of force main. ❑ Detail and model of pump or automatic siphon, including ❑ Ground slope with 2' contours in entire area of soil absorption system extending 25' minimum on all sides. size, pump curves, drawdown, and average flow rate (GPM). ❑ Location of area suitable for replacement system - provide soil ❑ Cross section of dosing tank showing pump(s) or siphon(s). data. ❑ Construction details of septic, holding or dose tank if site VI. Systems in. Fill (Fill must be placed prior to plan submission.) constructed, or tank manufacturer if state approved. ❑ Total area filled (fill to extend 20 beyond edge of trench before side slopes begin.) ❑ Construction details and cross section of soil absorption system. ❑ Depth and type of fill. ❑ Copy of signed onsite report by county or district staff. SBD 6678 (R. 08/83) (Plb 100a) (Wis Stats. S. 145.02) STATE OF WISCONSIN DILHR"__/<~_1_) 0 Detach And Return Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 141 Any Return Correspond P.O. BOX 7969 ro MADISON, WI 53707 608-266-3815 DATE:( `I t1~ 2 ~~FG r PROJECT: Yee, n CbrC Y alp. roix I.~:! Helyeson Truc!J ij, I. c. It Route 2 Sgtri tiq Vu i l e.v, I'RI «7isI PLAN ID. - DETACH HERE i}eurciss, Peter - NFCsicc_ricF_ PLANID. O i . # PROJECT NAME P This is to acknowledge receipt of your plans and specifications for the above-indicated project. ti;i. Preliminary review indicates the required fee is $ Fee Received is $ Plan accepted for review. X Underpayment- Please submit additional fee. Plans will be held in abeyance. ❑ Plans being returned. ❑ Overpayment-Refund forthcoming. ❑ Additional information required. SEE BELOW. ❑ No fee has been remitted. Plans will be held in abeyance. 1. Plan Submission ❑ Soil boring and percolation test data on 115 completed ❑ Additional information shall be submitted in duplicate unless by Certified Soil Tester. (1 copy) specifically noted. ❑ Petition For Modification signed by county, owner and ❑ Plans not clear, legible or permanent. notarized. (1 copy) ❑ All information submitted shall be signed, dated and sealed or ❑ Complete data relative to anticipated use of building. stamped in accord with Section ILHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required. 0 copy) Administrative Code. ❑ Affidavit enclosed. ❑ Condominium declaration. (1 copy) ❑ Plot plan showing location of land parcel (distance from nearest road intersection, etc.), lot size and all distances from IV. Holding Tanks private sewage system to buildings, lot lines, well, water- ❑ Holding tank profile showing vent, manhole, alarm, course, swimming pools, water service piping, all weather ser- and manufacturer if state approved. Complete vice road, etc. Show benchmark with permanent elevation. construction details if site constructed. ❑ Holding tank agreement signed by owner and local II. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed). ❑ Application for Use of an Alternative System signed by owner ❑ Reason for installing holding tank. Statement from and notarized. (1 copy) county or soil boring and percolation test data on ❑ County cnsite required. (1 copy) ❑ Design calculations. 115 completed by CST, showing that a soil absorption system ❑ Soil boring and percolation test data on 115 completed by cannot be installed on the land parcel. Certified Soil Tester. (1 copy) ❑ Aff idavit for all-weather service road (enclosed). ❑ Cross section of system. ❑ Pipe lateral layout. ❑ Plan view of system. V. Dosing Information ❑ Verification fo Exception Status Form by county. (1 copy) ❑ Calculations for total dynamic head and gallons pumped per cycle. III. Private Sewage Systems ❑ Size, length and depth of force main. ❑ Ground slope with 2' contours in entire area of soil absorption ❑ Detail and model of pump or automatic siphon, including system extending 25' minimum on all sides. size, pump curves, drawdown, and average flow rate (GPM). ❑ Location of area suitable for replacement system - provide soil ❑ Cross section of dosing tank showing pump(s) or siphon(s). data. ❑ Construction details of septic, holding or dose tank if site VI. Systems in Fill (Fill must be placed prior to plan submission.) constructed, or tank manufacturer if state approved. ❑ Total area filled (fill to extend 20' beyond edge ❑ Construction details and cross section of soil absorption of trench before side slopes begin.) system. ❑ Depth and type of fill. ❑ Copy of signed onsite report by county or district staff. S T C 9 9 INSPECTION REPORT St. C&Oix County Zoning 066ice ame o nema es ate San clany Perms t um etc D', d- - Locatcon W 4 Section l T N- R I S W, Townbadp ( 1 ebb ct PLCmbeA I 0 ate ( q ebb t2r• ' F t' \ 50 OWAPA- Ad - ~l 266 rc } e 2 ~.c ~ raSS L~ Sr'~ o a gl / L l )l .1 1 2 -.23 1y ' o r sly 7~a ' e BS Z 6 3 O It v~e_ a h 64- n a'' ~'~Sf eft ~U C :-q'e Cv Di6 cubb a K gna tuh.e 5184:m1 gnatune 0.6 1 Petition for Modification of an WISCONSIN DEPARTMENT OF OFFICE USE ONLY _ Administrative Rule INDUSTRY, LABOR AND HUMAN RELATIONS Petition No. DIVISION OF SAFETY & BUILDINGS PRIVATE SEWAGE P.O. BOX 7969, MADISON, WI 53707 ID-No. Name of Owner Building Occupancy or Use Agent, Architect or Engineering Firm or P 1 e r os Master Plumber Company Tenant Name, if any -Street No. Building Location, Street & No. Street & No. Cit ' State & Zip City County City State & Zip t. ill c: s Phone Plan Numbers (If Known) Phone - 7 - Y SS `type of Petition Set Backs (Soil Absorption Experimental and FeeT LL 1 ❑ and Septic Systems) ❑ Loading Rates ❑ Site Evaluations LEGAL DESCRIPTION AIIA-) t/a, Section , T N, R S r) W, Township Subdivision Name ..,f {f County N IN ADMINISTRATIVE RULE BEING PETITIONED V 1. Rule dl~ .a~ UVIf the Wisconsin Administrative code cannot be entirely satisfied due to the following reasons: - - - - - - - - - - - - - - - - - - - - - - - - - - - _1Et_CQ~os ~c~~_~pcp h _rt 2. In lieu of complying exactly with the rule, the following alternative is proposed as a means of providing an equivalent degree of safety or health: Le- - - - - - - - - - - - - C ing arguments (For, site evaluations, include Form 115="Report on Soil Boring and Percolation Tests") 'A 777- r DILHR SBD-6689 (R.12/81) (OVER) e i