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HomeMy WebLinkAbout018-1005-10-100 St. Croix County Planning and Zoning Thursday, March 15, 2007 at 12:31:22 PM Page 1 of I Detail Sanitary Information Computer 018-1005-10-100 Sub/Plat: NA Section: 2 Parcel 02.29.17.32B Lot: 1 TN/RNG: T29N R17W Municipality: Hammond, Town of CSM: Vol. 06 Pg. 1640 114114: SE 1/4 SE 114 Owner: Johnson, Harold, Jr. 1982 110th Ave. Baldwin, WI 54002 State Permit: 17584 Issued: 05/1211980 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permit: 48 Installed: 0511411980 POWTS Detail: Bed - Seepage Bedrooms: 2 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Harald Barber Yes Boldt, Everett plot plan for a house trailer on this parcel - not $0.00 hooked up at time of inspection. Assume the Tom Nelson Signed Off: Yes reconnection was for later house construction. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner: Johnson, David 1982 110th Ave. Baldwin, WI 54002 State Permit: 75038 Issued: 04/08/1986 POWTS Dispersal: Non-Pressurized In-ground Permit: Reconnection County Permit: 0 Installed: 04/08/1986 POWTS Detail: Bed - Seepage Bedrooms: 2 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Harold Barber Unknown Hudson, Dale data from notecard only - located original permit $0.00 and will file it with 1986 reconnection permit Tom Nelson Signed Off: No Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 4/8/2005 4/8/2006 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Parcel 016-1033-60-000 03/15/2007 11:06 AM PAGE 1 OF 1 Alt. Parcel 15.30.15.248A 016 - TOWN OF GLENWOOD 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 WILLIAM & BONITA MCCLUSKEY O - MCCLUSKEY, WILLIAM & BONITA 1490 HWY 128 GLENWOOD CITY WI 54013 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1490 HWY 128 SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 35.500 Plat: N/A-NOT AVAILABLE SEC 15 T30N RI 5W SE SW EXC 3.1 ACRES IN Block/Condo Bldg: P248B & EXC PT TO LOT 1 CSM 9/2677 EZ-U-1214/210 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-30N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 809/588 07/23/1997 806/192 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/26/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 32.500 3,300 0 3,300 NO UNDEVELOPED G5 2.000 400 0 400 NO OTHER G7 1.000 4,500 1,000 5,500 NO Totals for 2007: General Property 35.500 8,200 1,000 9,200 Woodland 0.000 0 0 Totals for 2006: General Property 35.500 8,200 1,000 9,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch 116 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 018-1005-10-100 03/15/2007 12:28 PAGE 1 OF 1 F 1 Alt. Parcel 2.29.17.328 018 - TOWN OF HAMMOND 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 - SCRIBNER, STEPHEN L & BARBARA J STEPHEN L & BARBARA J SCRIBNER 1982 110TH AVE BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1982 110TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 2.270 Plat: N/A-NOT AVAILABLE SEC 2 T29N R17W PT OF SE SE 1.14AC LOT 1 Block/Condo Bldg: CSM 6/1640 & PARC DESC AS COM SE COR SEC 2; TH W ALNG S LN 807.6FT TO POB; TH N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 275FT; TH E 180177; TH S 275FT;TH W 180FT 02-29N-17W TO POB (LSAO) Notes: Parcel History: Date Doc # Vol/Page Type 02/05/2003 708308 2131/249 WD 07/23/1997 1217/488 WD 07/23/1997 1217/487 WD 07/23/1997 752/601 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/18/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.270 28,200 185,800 214,000 NO Totals for 2007: General Property 2.270 28,200 185,800 214,000 Woodland 0.000 0 0 Totals for 2006: General Property 2.270 28,200 185,800 214,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 102 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 016-1033-20-000 03/15/2007 11:06 AM PAGE 1 OF 1 Alt. Parcel 15.30.15.245 016 - TOWN OF GLENWOOD 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 - MCCLUSKEY, WILLIAM & BONITA WILLIAM & BONITA MCCLUSKEY 1490 HWY 128 GLENWOOD CITY WI 54013 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 38.500 Plat: N/A-NOT AVAILABLE SEC 15 T30N R15W NE SW EXC PT TO LOT 1 Block/Condo Bldg: CSM 9/2677 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-30N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 809/588 07/23/1997 806/192 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/26/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 37.500 3,100 0 3,100 NO UNDEVELOPED G5 1.000 100 0 100 NO Totals for 2007: General Property 38.500 3,200 0 3,200 Woodland 0.000 0 0 Totals for 2006: General Property 38.500 3,200 0 3,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 018-1005-10-000 03/15/2007 12:27 PAGE 1 OF 1 F 1 Alt. Parcel 02.29.17.32A 018 - TOWN OF HAMMOND 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 - JOHNSON, ROBERT T & NANCY A ROBERT T & NANCY A JOHNSON 1963 110TH AVE BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 37.730 Plat: N/A-NOT AVAILABLE SEC 02 T29N R1 7W SE SE EXC Block/Condo Bldg: (P32B)018-1005-10-100 & EXC PARC DESC IN 1217/487 Tracts : (Sec-Twn-Rn9 40 1/4 160 1/4) 02-29N-17W Notes: Parcel History: Date Doc # Vol/Page Type 04/16/2003 717590 2208/383 WD 1217/488 WD 1217/487 WD 943/164 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/13/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 35.000 4,300 0 4,300 NO UNDEVELOPED G5 2.730 300 0 300 NO Totals for 2007: General Property 37.730 4,600 0 4,6000 Woodland 0.000 0 Totals for 2006: General Property 37.730 4,600 0 4,6000 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 016-1033-20-000 03/15/2007 11:33 AM PAGE 1 OF 1 Alt. Parcel 15.30.15.245 016 - TOWN OF GLENWOOD 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 WILLIAM & BONITA MCCLUSKEY O - MCCLUSKEY, WILLIAM & BONITA 1490 HWY 128 GLENWOOD CITY WI 54013 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 38.500 Plat: N/A-NOT AVAILABLE SEC 15 T30N R1 5W NE SW EXC PT TO LOT 1 Block/Condo Bldg: CSM 9/2677 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-30N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 809/588 07/23/1997 806/192 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/26/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 37.500 3,100 0 3,100 NO UNDEVELOPED G5 1.000 100 0 100 NO Totals for 2007: General Property 38.500 3,200 0 3,200 Woodland 0.000 0 0 Totals for 2006: General Property 38.500 3,200 0 3,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT OWNER "-bold 'SAXNg©h, fir, TOWNSHIP \kQmrnondSEC. 2 T Zq N, R 17 W ADDRESS t., ST. CROIX COUNTY WISCONSIN, nl ►.~i~n leis. SUBDIVISION LOT LOT SIZE S~cr~e~• PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHO EVERYTHING WITHIN 100 FEET OF SYSTEM c 14 I di a e No th Arrow ' i 17 -1 1 J_ I SC L : f of Sc zLi~_i SEPTIC TANK(S) he MFGR. _ )eise(- s . CONCRETE STEEL 0. o rings on cover r)ne- Depth PUMPING CHAMBER SIZE PUMP MFGR. DEL NO. GALLONS Per Cycle TRENCHES NO. of wit length area BED NO. of lines Luo width length (05 area 780 depth to top of pipe 0 NUMBER OF SEEPAGE FITS Outsi a iameter total pit area AGGREGATE 1 X I ZA c PERK RATE A REQUIRED '750 ° AREA AS BUILT 7,90 ° Disclaimer: The inspection of this system by St. Croix-.Cdunty does not im y complete compliance with State Administrative Codes. There are other are~that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS INSPE DATED J ` ly _ PLUMBER ON JOB LICENSE NUMBER St. Croix County Planning and Zoning Tuesday, October 03, 2006 at8:53:11AM Detail Sanitary Information Page 1 of 1 Computer 018.1005.10.100 SublPlat: NA Section: 2 Parcel 02.29.17.32B Lot: 1 TWRNG: T29N R17W Municipality, Hammond, Town of CSM: Vol. 06 Pg.1640 114114: SE 114 NW 114 Owner: Johnson, David 1982 110th Ave. Baldwin, WI 54002 State Permit: 75038 Issued: 0410811986 POWTS Dispersal: Non-Pressurized In-ground Permit: Reconnection County Permit: 0 Installed: 04/0811986 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuerllnspector As Built Plumber Other Requirements Additional Notes Money Owed Harald Barber Yes Hudson, Dale locate original permit (if available) in 1978-81 data from notecard only $0.00 Tom Nelson Signed Off: No archives Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 418/2005 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - JOHNSON, DAVID o~JvI &V ~S10-160 n 2 Rt. 2 ! L9_ll _ T29N-R17W, Baldwin, WI 54002 Town of Hamtriond San.Permit#75038 4-8-86 D. Hudson j Conventional, Reconnection L-OJ""r j YO Parcel 018-1005-10-000 /605- 26 10/03/20 P06 08:46 AM AGE 1 OF 1 Alt. Parcel 02.29.17.32A 018 - TOWN OF HAMMOND 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 - JOHNSON, ROBERT T & NANCY A ROBERT T & NANCY A JOHNSON 1963 110TH AVE BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 37.730 Plat: N/A-NOT AVAILABLE PI-F5-10-00 SE EXC Block/Condo Bldg: CZZ X18-1005-10-100 EXC PARC DESC IN 1217/48; Tract(s): (Sec-Twn-Rng 401/4 1601/4) 02-29N-17W Notes: Parcel History: Date Doc # Vol/Page Type 04/16/2003 717590 2208/383 WD 1217/488 WD 1217/487 WD 943/164 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/13/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 35.000 4,300 0 4,300 NO UNDEVELOPED G5 2.730 300 0 300 NO Totals for 2006: General Property 37.730 4,600 0 4,600 Woodland 0.000 0 0 Totals for 2005: General Property 37.730 4,600 0 4,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 CERTIFIED SURVEY MAP LOCATED IN PART OF THE SE 1/4 OF THE SE 1/4 OF SECTION 2, T29N, R17W, TOWN OF HAMMOND, ST. CROIX COUNTY, WISCONSIN. OWNER LEGEND HAROLD E. JOHNSON JR. 0 1" x 24" IRON PIPE WEIGHING RT. 2 1.68 LBS/LINEAR FOOT, SET. BALDWIN, WI. 54002 unplatted_lands _owned_by_platter EAST 180.001 0 ~o -900 ~n N w Uri UI I sr I ~ m m i s i cat Ift LOT 1 o 0 iw z is 0 o' sz 10) H existing house is & shed N 0) ft n o is is U) 'P N 0 f U1 N C 10 to (DD IE ° \ o x IE N O ~ I~ iw o la N I O 0 I C3 J ICJ ro 49,500 sq. ft.) IN. ROAD R/W c fb IN 1.14 acres ) O 1~ 1W - I (t 43,560 sq. ft.) EX. ROAD R/W IIrt rf 0 IcD 1.00 acres ) in M Ifi tD WEST 900 18 .00, W 0 O TOWN ROAD o ° 180.00' ° 807.60' WEST S 1/4 CORNER south line of the SE 1/4 SE CORNER SECTION 2 SECTION 2 CO. MON. CO. MON. others 'ig~~oastr3i♦ unPT-atted lands owned by ;ry ALLEN C. NYHAGEN 5.1407 = 50 25 0 b U HUDSCN o ~ma this instrument drafted by Douglas Zahler job no. 86-12 b.< ~ NO e0~~?l 4A ~IOT~ DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR TY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 )<UlREAU OF PLUMBING MADISON, WI 53707 fr' RCONVENTIONAL ❑ALTERNATIVE State Plan L D. Number + Illf assigned) ❑ Holding Tank O In-Ground Pressure O Mound RECONNECTION NAME OF PERMIT HOLDER: ]ADDRESS OF PERMIT HOLDER: INVF_CTION DATF: David Johnson Rt. 2, Baldwin, WI 54002 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN; REF. PT. ELEV.: CST REF. PT. ELEV.: SE SE, Section 2, T29N-R17W, Town of Hammond Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Dale Hudson 6629 St. Croix SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO BEDDING: JVENTDIA.: VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. FEET FROM LINE: AIR INLET: DYES ONO DYES ONO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO OYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING: V NTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 I H DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA #PITS: LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPTH: DIMENSIONS .HAVt1_ DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH 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 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. DYES NO SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS DYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED. SEEDED: ULCHED: CENTER. EDGES'. DYES ONO DYES ONO MDYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE.: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: 1NO,DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKINGELEV.: ELEVDIA.ELEV.PIPS: DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL: PLANS. LIFT CORRESPONDS TO APPROVED DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES ONO DYES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. URE: TITLE: DILHR SBD 6710 (R. 01/82) SIGNAT w'SC°^5'" APPLICATION FOR SANITARY PERMIT • D I LI_ H R• (PCB 67) St" Cdl- t X COUNTY - I Ia oec+cvatrr~nTOC UNIFORM SANITARY PERMIT tnousTFW LF4Ek0R f iurrw~n raTions r(/ ~ -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 3>4V id a PROPERTY LOCATION 54114 51 /4, S 2 , T 4 ?N, R /'70! for TOWN O al"I" can/X LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN LD. NUMBER Z& Zee.. TYrPE~ OF BUILDING OR USE SERVED - /M 0 / Q5 l0 -/00 y~ 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 ~~77 Vault Privy Pit Privy Existing, For Which A Previous Permit Is On File, Permit # Z issued -5,- ~ - 19,?o An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total *of ` Prefab. ` ite Steel Fiberglass Plastic Gallons Tanks Concre Co ucted' Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total *of fab. Site Steel Fiberglass Plastic Gallons Tanks 04ncrep Constr c ad Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer. PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square feet): PROPOSED (Square Feet): Z 47 Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP/MPRSW No.: phone Number: Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Sign t a a Of Issuing Agent: Fee: Date: r Q ❑ Disapproved El ~t J O ~0 Approved Owner Given Initial Adverse Determination eason 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 si r C►~Jd ~ ~s 17 VIE 0~ SANITARY PERMIT ~ DILHR Coon - ~„GROUNDWATER SURCHARGE Sanitary Pemlt No. L 7,0.~~ 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> . Siena re of Issuing Agent: - Gndwater Fee: Date: WISco buried DILHR SOD-7289 (N. 05184) e t. 4 CH 115. Rev. 9/78 - REPORT ON SOIL BORINGS AND PERCOLATION TESTS , WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICE P.O. BOX 308, MADISON, WISCONSIN 53701 LOCATION: 515%, 56%, Section ,T&LN,RL2Be(or)11LTownship or MunWpelity- A91" ✓ gl Lot No. , Block No. Subdivision County c;1~ • CRo x rvlslon a Dwner's/Buyers Name- 0 /L Cot m Mailing Address: Ot Z Lj; S TYPE OF OCCUPANCY: Residence X No. of Bedrooms- wO COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS" - g0 SOIL MAP SHEET 150-1 NAME FSOILMAPUNIT PERCOLA ION TESTS TEST HO R3 WATER IN TEST TIME DROP IN WATER LEVEL, INCHES NUM- DEPTH CHARACTER SOIL SINCE OLE HOLE AFTE INTERVAL RATE BER INCHES THICKNESS IN INCHES 1,10 1ST WE ED SWELLING IN MINUTES PERIOD I PERIOD Z PERIOD 3 MINAN P- 1 , S. CI„ ,~-M r e p p L D IP- A Ir It " A o O /S01. It J P- ll •I / it " a o 0 ZhL J-1 1P- 11 ~I ~41 .24 IYA O Y go P_ .1 o 7 P_ I O ,I Oc f d 1 3z SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES 8- 6 6' B- v y •,1 11 • n h H a- I Lij r ~~~p N N ~I 4 Z- /PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Gh* horizontal and vertical reference points. Indicate slope. e i~le gial L __t g ► J ` 9 Is .1 irk 1 - fi - Oi-- oll, -fir- i, Ow I rAwsignW, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and method: spedfied in the Wisoonsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my wW bdW. Name (print) Q-~ D L T Certification No. ~S Addrea Name of installer if known o L CST Sign e ~A ~Aothority REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.ixany Penm.i.t • State Septic /7S S NAME ~Townbh.ip S Cno.ix County Location Section Z SEPTIC TANK I Size ,L&dog a.ttonb. Numben o6 CompaAtmen Vi4tance FAom: Wett 6z. 121 oA gneateA a.tope_ t Bu•i,td.ing'- 6t. Wex.tanda 6#. HighwazeA a 6z. ` . 'DISPOSAL SYSTEM • ,iA tance FAom: We.t.t_____T0 6x. 121 oA gAeatEk a.tope 6z• Bu.i.tding A At. Wettand.6 ~r Ft. H.ighwa#en~6t. FIELD DIMENSIONS: Width o6 tnenchit. Depth o6 Hock be.Low ti..Le-Z.L-in. 1 Length o6 each tine, St. Depth o6 Aock oveA ti.te Z .in. ~S 2 NumbeA o6 tin e4 Depth o6 z.i.te be.tow gxade.2Z in. 'Ln pen 100 6t. 0 tat .2eng.th o j 1-.ine.6 ~6t• S.ta pe o6 tneneh 1 5 G 0D.ia Lance between Una it. Depth to b edno ck 6 - Totat ab, onbtion anea_ZjL_6t2 Depth to gnoundwateA _ 6t- t2 Type o6 CoveA: Papik aA to •Requined area 6 PIT DIM€NSIONS HunbeA ,06 pitA ave.t aAound path yee no OutAide d.iameteA Depth be.tow .in.tet 6t• 2 Totat a.baoAbtion Ze a 6t 2 A AAea Aequtined 6 2 m INSPECTED TITLE APPRO VED~ , DAT € / 1918 REJECTE11 DATE 197 VAjo State and County State Permit # . PL19'67' Permit Application County Permit for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # Mailing Address: A. OWNER OF PROPERTY B. LOCATION: :5 E Section TQKI N, R -LZ V (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township Am 4AJi C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons-r~ & l`SA e m J D. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks QA) le, HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation X Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLU,E,NT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New J( Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top)-No. of Trenches Seepage Bed: X Length A I Width-Depth !6" Tile depth (top) c2q- I' No. of Lines ~we Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land ,62^ Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified oil Tester, NAME ✓ e,4 9.L o~l C.S.T. # S $W and other information obtained from W (owner/builder). Plumber's Signatu MP/MPRSW# Phone Plumber's Address L S~w "'00 1AJJ 'T PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. D , E z ~ Clot cS= m ; E.u t✓t..~ 0 R, h p ; 1 ; t F I - / • 7&V S t V/V Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application ,Z - So Fees Paid:, State 11'' O County !1 Date - Z -S~ Permit Issued/112i (date -7/Z - R 0 Issuing Agent Name 117- Inspection YesX-No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. Plumber (canary copy) Revised Date 7/1 /78 EH - 115 Rev. 9/78 r REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICE P.O. BOX 309, MADISON, WISCONSIN 53701 + LOCATION: •SE'/<, SE'/o, Section A,T¢VN,RJ_7D(or) W Township orMunie'leality. Am.-~oN 41 ~ CRo l x Lot No. ,Block No. County S1 'l / u ivision am Owner's/Buyers Name: /V,4k O C_/4 S o AJ c P_ Mailing Address: M Z- r S TYPE OF OCCUPANCY:. Residence X No. of Bedrooms w0 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEWREPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS' - ~O SOIL MAP SHEET 15'3 NAME qF SOIL MAP UNIT PERCOLA ION TESTS TEST DEPTH CHARACTER OF SOIL HO RS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES NUM- SINCE MOLE HOLE AFTE INTERVAL RATE BER INCHES THICKNESS IN INCHES -6 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P_ to 4 Alo 30 1-k- /A-_ A~ -A b P- 11 61 11 g R a A O O P- 11 o o y 23 1.34, (e /4 c, P- II rl rr Y a 5~ O f/ o P_ r o 0 7 3 4_0 P- O O" v SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATE/!D HIGHEST IF OBSERVED IN INCHES B- (0 B- ° y 4 V L Z ~l r/ l / 4 q rr r B_ !Za 6, B- J r~ y ~l (~O r /r U lI G~ I/ B- 2 If (r PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. S I E f ? Q ~-j~eP r ~ g E ~ Q~ Q ~ ~U t t . I OL eo~_ N ~ ~~A O o ~ I g E (N I s 1, the undersigend, 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 location of test holes are correct to the best of my knowledge and belief. Name (print) :LL- Certification No. Address 1'q, 6,J w ! S .Name of installer if known ✓ ° L e -16 Copy A -Local Authority CST Signa