HomeMy WebLinkAbout028-1051-10-000
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Parcel 028-1051-10-000 02/05/2007 01:27 PM
PAGE 1 OF 1
Alt. Parcel 35.28.17.331 028 - TOWN OF RUSH RIVER
Current I _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
JOE M & DANA M BAKKE O - BAKKE, JOE M & DANA M
1913 3RD 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: 11.200 Plat: N/A-NOT AVAILABLE
SEC 35 T28N R17W PT SW 1/4 LOT 1,2,9,& Block/Condo Bldg:
10 BLK E INC ALLEYWAY LYING BETWEEN SAID
LOTS VILLAGE OF CENTERVILLE & INC 485FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
LYING ELY OF CTR LN OF FIRST ST ON SAID 35-28N-17W SW
PLAT; BOUNDED ON THE N BY THE NLY LN OF
OAK ST EXTENDED ELY; AND BOUNDED ON THE
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
04/01/2005 791123 2775/557 WD
09/14/1998 587025 1357/042 LC
07/23/1997
07/23/1997 842/429
2006 SUMMARY Bill M Fair Market Value: Asse
166294 Use Value Assessment
Valuations: Last Changed: 08/30/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 20,000 172,600 192,600 NO
AGRICULTURAL G4 10.200 1,600 0 1,600 NO
OTHER G7 1.000 3,300 2,800 6,100 NO
Totals for 2006:
General Property 12.200 24,900 175,400 200,300
Woodland 0.000 0 0
Totals for 2005:
General Property 12.200 24,900 175,400 200,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 566
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
t
• .r
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER r~
TOWNSHIP SEC. T N-R /7 W
ADDRESS 10 ST. CROIX COUNTY, WISCONSIN
.S~UDZ-
SUBDIVISION LOT /4 - LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1z"I
Yc~nf~
33' It
a)e
rgrr»
Rouse
D
I ( ( I ~
INDI ATE NORTH ARROW
l~ r 9z" S-¢
BENCHMARK. Describe the vertical reference point used ?o Moin ,
Elevation of vertical reference point: Proposed slope at site: 5~ /o
SEPTIC TANK: Manufacturer: se,,-- Liquid Capacity: •
Number of rings used: ~YI
C Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front , Side,0 Rear, O ~40
feet
From nearest property line Front,® Side,0 Rear, O '7"0,
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: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
elevation:
V
Elevation of inlet: Bottom of-lank
i
Pump off switch elevation: G 11 ns per cycle:
a Switch Alarm Manufacturer: ~ Type:
Ft.
Number of feet from nearest 45~y 1 e: Front, O Side, O Rear,
0
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: yew Trench• ^
`~~n p
Width: AZ Len$th: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, (l;~A Side, O Rear,O Ft .
Number of feet from well: 4 -
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: ` iameter:
FseeTage it elevation:
Liquid depth: Bott7/
Area Built: Has either a drop box O or distri utio~ b x bee used on any of the above soil
absorbtion sytems? (Check one). i
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: F-1/0- vation of bottom of tank:
Elevation of inlet:
Number of feet from nearest ypro,/,e ty li e: ront, O Side, O Rear, OFt.
Number of rom e
Number of fee ldin
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: - ~0'/9 Plumber on job: Q/e 'Z--
y~2
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O:BOX PRIVATE SEIIVAGE SYSTEMS DIVISION
79691 BUREAU OF PLUMBING
MADISON, WI 5370
aCONVENTIONAL OALTERNATIVE state Plan LD. Nomber
(lf assigned)
E Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME O PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE
Richard Bakke Rt. 2 Baldwin WI 54002 O 44
BENCH MARK (Permanent reference P-,O DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.. CST REF. P ELEV
S% of the SW4 of Section 35, T28N-~R17W Town of Rush River
Namr• of Plmnl- IMP/MPRSW Nc, County Sanitary Permit Numl~ar_
Dale Hudson 6629 St. Croix 83808
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LI ID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV WARNING LABEL LOCKING COV EH
~y/ J PROVIDED PROVIUED
BEDDING. 7~ DYES NO DYrA ONO
VENT DIA. VENT MATIL I(4& ER NUMBER OF ROAD: PROPERTY WELL BUILDING ENT TO FRESH
AL FEET FROM LINE H IN LET
DYES ONO DYES O NEAREST r t~> 13
DOSING CHAMBER:
MnNUFnCTUHER BE RUING JILIOUT) CAPACITY PUMP MODEL PUMP: SIPHON MANUFACTURER A'j WARNING LABEL 11L-OOCVK~NDEGD
COVER
PRO
VIDED.
DYES ONO DYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. :13 PR(ri'F HTV WFLL BUIFUIN({ (VENT TO IRISH
(DIFFERENCE BETWEEN NE 41R INLET
PUMP ON AND OFF) DYES ONO
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NIF TER %IATI HnND Kmt;
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:
BED/TRENCH WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSI;P LIQUID
TRENCHES M EHIAL
DIMENSIONS Z ® ~O PIT DEPTH
(,HAVEL DEPTH FILL DEPTH F)ISTH PIPE DISTH PIPE DISTR. PIPE MATERIAL N~tTNE
BE LOW PIPES ABOVE COVER F V INLF T EL PER TV WELL BUILDING VENT TO FHF SH
UMBER OF
M LINQA 71NLE
ET FRO
9-~' 371
AREST
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-
DYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL CO
VER TFXTUHE aeFaMnNINrMnHKF OBSIHVnTrzlNwllls
HS
DEPTH OVER THE NC HBED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SDDUEI) DYES ONO OYES DNO
CENTER EDGES SEE UFI) IM11ITC1111)
DYES ONO DYES ONO EYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING (iHAVEL UEPTH BF LOW PIP! FILL DEPTH AHOVf COVFH
TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MAT EHIAL ND DISiH I:ISTH PIPE DlSililBll I ON PIP( MAN HIAI t1 M11 nftK IN(,
ELEVATION AND ELEV ELEV CIA ELEV PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPnGING DRILLED CDF2H EC7 LV COVFH MA7EHIAL
VEH TICnL LIFT CORRESPONDS TO APPHOVI U
PL nnis
DYES DNO NO
ONO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. E PROPERTY WELL. BUILDING
NUMBR OF LINE
2 I - FEET FROM
YES ONO DYES ONO NEAREST
DID
Lfj''~
S- 0~
Sketch System on
Reverse Side. to in county file for audit.
SIGN r TITLE
DILHR SBD 6710 (R. 01/82) `
i
DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE ITARY ERMIT#
-Attach complete plans (to the county copy only) for the system, on paper not less than Off8% X 11 inches in size. STATE PLAN I.D. NUMBER
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION
FOR VARIANCE ❑ YES )dJ NO
PROPERTY OWNER PROPERTY LOCATION
71
114&-'
-S% Sly'/4, S -3:5' T2K, N, R fH (or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY, STATE TE A44
ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR ANDMARK
E3 VILLAGE : s > ✓G°Y' .Y~/
400_ If 116, X TOWN OF
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): A/~
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. ❑ New b.,M Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. Seepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet) : PROPOSED (Square Feet):
7&U Feet ❑ Private ref
J~1 Joint ❑ Public
VI. TANK CAPACITY
in allons Total # of Prefab. Site
INFORMATION New Existing Gallons Tanks Manufacturer's Name Con- Steel Fiber- Plastic Exper.
Tanks Tanks Concrete structed glass qpp.
Septic Tank or Holding Tank /p0 C7 F] I ❑ ❑ ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
Name of Designer:
Vlll. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name
CST #
CST's ADDRESS (Street, City, State, Zip Code)/
Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved El Owner Given Initial I-e Surcharge Fee .
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning yo:}r privat< sewago syste, -i, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Pro`,)ide the legal description where the system is to be
installed;
Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g..
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater, protection law. This change in statutes was the i
result of over 2 years of steady negotiation and public debate. The groundwater bi(I Groundwater
included the creation of surcharges (fees) for a number of regulated practices which WiscorYsin's'
can effect groundwater. The surcharge took effect on July 1, 1984 All of the water that buried treasure A
is used in your building is returned to the groundwater through your soil absorption
system or the disposal site used by your holding tank pumper.
The monies collected through those surcharges are credited to the groundwwer fund adminis-
tered by the `department of Natural F.-~so =rcet-. These funds are used for monitoring ground 1 - _
water, ge)undwater contamination ir?;es{;gatic_nns and establishment of standards. Ground swat,,
it's worth protecting.
SBD-6398 (8.03/86)
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 inadequaoies 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 41560 It. Section--3 ~5 , T .2 N - R /7 W
Township r -
Mailing Address e7
30 101ev 0-
Subdivision Name
Lot Number &14
Previous Owner of Property Al 7 ce al &ze j~ .
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes J_ No
Volume y 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.
PROPERTY OWNER CERTIFICATION
I (We) eeAti.6y that a t a.tatemen A on this 6o4m ace tAue to the but o6 my (oun)
knowledge; that I (we) am (ane) the owneh(a) 06 the pnopehty deacAi,bed in thiA
in6onmation 6ohm, by viAtue o6 a wanh.anty deed Aeeonded in the 066ice o6 the
County RegiAten o6 Deeda as Document No. 425' 4 and that I (we)
ptuently own the p.4opoaed .bite 6oh the aewage~poaa 6y6tem (on 1 (we) have
ob.ta.i.ned an eaa emen t, to hun with the above dea eh,i.bed ptopen ty, bon the
constAuction o6 aa,id aya.tem, and the name has been duty Aecotded in the 066.iee
o6 the County Re9i,6 ten o6 Deeds, as Document No.
SIGNATURE OF~OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
7
DATE SIGNED DATE SIGNED
• H
z
fn
H
STC-105 r
9
SEPTIC TANK MAINTENANCE AGREEMENT ryi
St. Croix County z
ty
y 9
OWNER/BUYER
ROUTE/BOX NUMBER, Fire Number
.CITY/STATE ZIP S~pj~ Z
PROPERTY LOCATION: j P49 5W ;4,/Section, T_Z? N, R 17 W,
Town of {jc~SfJ 7e" ye r St. Croix County,
Subdivision AIX Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in-the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (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.
0
I/WE, the undersigned, have read the above requirements and agree z
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- 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.
SIGNED
DATE Z ~C
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP 0. BOX 76
N WI 53707
HUMAN RELATIONS (H63.09(1) & Chapter 145.045)
LOCATION:- SECTION: TOWNSH~MUNICIPA ITY: LOT NO.:BLK. NO: SUBDIVISION NAME:
S ~ tv'/ /T,?BN/R/7R (o W
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
USE
DATES OBSERVATIONS MADE
NO.BEDRM&. COMMERCIAL DESCRIPTION: PROFILE DES RIPTIONS: R LATION TESTS:
Residence ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(opti nal)
®S ❑u S ❑u 2S au El ®u EIS ®u
If Percolation Tests are NOT required DESIGN RATE: I If an
y portion the tested area is the
under s,H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
F PROFILE DESCRIPTIONS
BORING TOTAL PT
ELEVATION H TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH M OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
i
B- 2- 9-'2?1Sd-
ZZ
l
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER llle"E6 AFTERSWELLING INTERVAL-MIN. p Rlnp I PERT D2 PER _ PER INCH
P
to- C/
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 9(/P
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print
TESTS WERE COMPLETED ON: /
ADDRESS: Dole 7 - / r~CO
CERTIFICATION NUMBER: PHONE NUMBER (optional):
26Y 00
CST SIGNATURE:
01
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) OVER -
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Wisconsin Department of Health end 5ooial Services
Plb• #67 10/69 Division of Health
PERMIT APPLICATION
for
PRIVATE DOMESTIC SEWAGE SYSTEMS
A. OWNER OF PROPERTY TYPE OR USE BLACK INK-
Name Address (Street, City, Zip Code)
Bichar. Bade Baldwin, Wisconsin"
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTF.IM f County
Check One: ~
CITY VILLAGE LEGAL DESCRIPT1ONt S 5/ / ~
TOWNSHIP Rush River Section 35 Ste Orsia '
A~ e!
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? X YES NO - s PERMIT NUMBER
D. SEPTIC TANK CAPACITY 1000 Gallons NEW INSTALLATION X REPLACEMENT ADDITION
MATERIALSt Prefab Concrete X Pour ~d in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: 6130
Ee TYPE OF OCCUPANCY Trailer
Check Ones One or Two Family Residence Commercial Industrial Other
-
Number of Persons to be Acoommodited 3 Number of Bedrooms Two (specify)
F. APPLIANCES, Ms Food Waste Grinder YES X NO Automatic Clothes Washer YES JX NO
Dishwasher YES NO Automatic Potato Peeler YES 'X NO
Other (Specifly)
G. EFFLU':;YT DISPOSAL 4~S'= NEW X EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet 75Trenc'sz Width Zr- Depth 3r Number of Lines
Seepage Bed: Length Widtj~„ Depth Tile Size No. Lines
Seepage Pits Inside diameter 5 Liquid Depth 5p
P E R C O L A T I O N T E S T
Test Depth Chamaoter of Soil Hours Water Test Time Dro, in Water Level Inches Minutes
Number Inohea Thickness in Inohes Since Hole in :;ole Interval Second to Next to at To Fall
Example 1st Wetted Overni ht lin Minutes Last Period Last Peri Period One Inch
P- 0 360 Top Soil. 10'x. Clk%. 2611 25 es or no 30 1/2 1/2 1/2 60
1 360 Top soil 60 Qr. 3 N 24 ITO 30 11 10 10 6
2 N N N N0 4 10 9 g
3 N N N N Na N 10 9 9 7
RECORD DATA FR(.n MINT"A OF 3 TEST HOLES
ompute size of absorption area in accord with H 62.20 Wis. Administrative Code.
SOIL BORINGS - MiniLS4„361, Below Pro osEA Absorption System
oring Total Dept`; Depth to Ground Water D_e?th to Bedrock
rook --I
umber Inohea Observ c !Estimated Oervad Estimated Cte+. cter of Soil with Thioknesa in Inches
xample
0 72', 72`0
Biaok ''op Soil 1211: Clay 1811: Sand 1 k; Gravel 2411
' 4
V2 no @ Nome Top soil 64 Gravel & :lay 664
2 4 N N 4 N 4
3 N N N N n a
1
RECORD DATA FROM MINIMUM OF 3 HURE HOLES
COMPLETE OTHER SIDE
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me
or under by supervision in accord scith the procedures and method specified in Chapter H 62.20 (3),
Wiaoons''.~ Administrative Code, and hat the data recorded and location of test holes are correct to
the best of my knowledge and belief.
NAME Zvereztt B*ldt TITLE
Type or Print)
REGISTRATION 1W. or MASTER PLUMBER LICENSE No. 4+89
ADDFtJsS Baldwin, Wiecc►nsin
DATE SIGNATUF6
MASTER PLUM3ER ATION MP `t 1~~~`ta,~
g
SignaturTNG
License Numbers
f V-, ASW
(To be Completed by Issuin;c Agent)
Date of Application Fee Paid = h 47
Permit Issued (date ? x- z Permit Number
Agent (name) .3 ,4 For: ii A;7'
Town, Vill-+-ge, City; County, etc.
(Specify)
Notes The application cannot be considered for filing until all of the above questions are answered
and the fee I-eld. Agents will. forward application, the fee of $10.00 and Copy (b) of the
Permit (yellwy cosy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
Do not write in space below - j~F;OR DEPARTMENT USE ONLY
DATE RECEIVED ACCEPTED BY / RETURNED
(Initials) / (Date) See Corres
FEE RECEIVED v VALID. NO. 6 PERMIT NO.
Yes or No)
REVIEWED BY _ APPROVED _ DATE
(Initials) Yea or No)
COMMENT'S :
-end':1
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