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HomeMy WebLinkAbout030-1078-80-120 n co p 3 v 0 d _1 o f i c d o n 3 T 7! 3 m # o Q • o w _ 0 OJ w o o ° w 00 co IQ ° 3 r- 00 (DD 5- c o co (a c- w ° fD CD f0/ _ C] U] N N O CD w ` 11 cn =r ~j -0 -j C) CD r_ CD L' N an O~ fD O Ill N ro n N r~ n y ° ~J (D rt (D [fin p ~i T o p w o CD rt y N a a o H- V I~ W c a Ic m p N 00 H b 3 ° V 00 H rt =*t i. co w o "wail ,t-- o ;d y ww cOnc c N rn rn _ c a s, In cn F- (D Q r~ N =i Cl) z l~rl rt o d = r'3= 0) (a (A fA C1 M Cil 00 W O O !V N N 00 N 0) m 3 tT ~-7 H Z w Li z co z Q 0 O D a l~1• d o ~d Cl) f-h CD CD 0) CD N C~ rt n m p' rt w a N• o F o 0 z CD co to rt 0) b a A z o' 00 7 z PO W o CL z I w m a 3 m a ~ o - I 3 n~i c 3 o o a n y a I 4z A I O y+a I ti a p b ~~v CD va °w O o r ow ° a q Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP S ZdsC,- SEC. T N-R W ADDRESS ST. CROIX COUNTY WISCONSIN Ti, 7-, SST SUBDIVISION f~,4 LOT LOT SIZE !y F PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM nrGtJ Co T STATE r~~~ ~ loan v r No/?r# P'R L . sAk"A.4c Pik L ~ yo SXsT~r~ FL, I A9G` r ji~c o /~os~r~ 0;.7-3 t3A~rc ff~A/~c-2 /D,2, ~O ~ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used AIX Z07- TA A'h~:7- Elevation of vertical reference point: / l'o Proposed slope at site: - SEPTIC TANK: Manufacturer: Liquid Capacity: ~d QQ Number of rings used: 3 Tank manhole cover elevation: 57/ Tank Inlet Elevation: Zj 3 Tank Outlet Elevation: 1'~2,5,00 _ Number of feet from nearest Road: Front,(IQNSide 0 Rear, Ofeet .From nearest property line Front, 0Side,k4jRear,0 f feet Number of feet from: well 2607- , building: y?( /Q & (Include this information of the above plot plan)( 2 reference dimensions to septic tank) ,1 A PUMP CHAMBER Ma acturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons cycle: Alarm Manufacturer: larm Switch Type: Number of feet from nearest operty line: t, O Side, O Rear, 0 Ft. N er of feet from well: Number of feet from building: Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: XAA 5 Trench: Width: Length: Number of Lines: 3 Area Built: 69 Fill depth to top of pipe: Number of feet from nearest Number of feet from well: It 00 0- Number of feet from building: (Include distances on plot plan). 189 AGE PIT Size. Number of pits: Diameter: Liquid depth. Bottom of seepage pit elevation: Area Built: Has either a drop box O or dist . ution box O been used on any the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Ca ity: Number of rings used: Ele ion of bottom of to Elevation of inlet: Number of feet from n est property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: ~~~c~~/P Dated: Plumber on Job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ' . LABOR & HUMAN RELATIONS SAFETY & BUILDINGS P.O. Box 7969 PRIVATE SEWAGE SYSTEMk-,,,- DIVISION M(>DISON,,WI 53707`;' 1 BUREAU OF PLUMBING tNw,lvw 6I 3c i[CONVENTIONAL ❑ALT~ERI gT State Plan I.D. Number: ❑ Holding Tank I1 r" °'a,~'9ned' 9 ❑ In-Ground Press 1 rya, w<„~r . ~ t~~ NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER l INSP., ION DATE: ~ Sad z HMV-Vs~k r~ SLMS • ~~il a PM BENCH MARK (Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN: C C'.TV I""y~~ EF. PT. ELEV.: CST REF. PT. ELEV.: 1 Z q . `19 1C . 00 Name of Plumber: 'C) MPlMPRSW No. Coumy Sanitary Permit Number: t tJ/a,v1.J Sct~w~l t~ 37?~ s, . c Rot>C SEPTIC TANK/ TANK: 6"lUol-SQ, SP-w,r-R V-L; N Iv' FRxq lacuS~ = ItJ Fc> MANUFACTURER: L IOUID CAPACITY. TANKINLETELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER W~~s PROVIDED PROVIDED: loco GAL IZS, z7 124"1 , YES ❑NO ❑YES p BEDDING: VEKT DIA.: OEM MATT JHIGH WATER NUMBER OF ROAD: PROPERTY WELL: fUIL~GVENT TO FRESH tRtSE~ I/.ySQ, ~_V ALARM FEET FROLINE I AIR INLETYES ❑NO 4-~i YES %0 NEAREST Zt opt DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID TPAND CNEMET UMP MOUE L. PUMPrSIPHON MANDE AC T I IRE H WARNING LABEL EOCK G COV ER PROVID EDED: ❑YES ❑NO ❑YES ❑NO ES ❑NO GALLONS PER CYCLE: ON TRO LS OPERATIONAL UBER OF PROPERTY ELL UILDING VENT TO FRESH (DIFFERENCE BETWEEN FFROM uNE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST--- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1111A11,11 TEH IIATI HIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: SjS. ULT.. V nTt 1071 BED/TRENCH WIDTH t LENGTH NO OF DISTH PIPE SPACING COVER INSIDE DIA -PITS LIQUID o TRENCHES MATERIAL: DIMENSIONS 1 > PA 6.U !InrNEr~C PIT >JA N~ DEIQA GRAY L DEPTH FILL DEPTH DISTR. PIPE DISTH PIPE lots R. PIPE. MATERIAL NO Dlsnf NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES ABOVE COVER EI E V INLf T ELEV. END PIPE S LINE. AIR INLET. 10 - i\ 3.tl lUj.~v~ 402.io WC #'nt~ 3'11 FEET FROM 1 , NEAREST --i► 1Z T5U 7Z5 7 Lam( MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES ❑ NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PE HMANf NT MARKERS OBSERVATION WELLS _ ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVFR TRENCH HED OEVTH OF TOPSOIL SODOFD SEF UFO MULCHED CENTER EDGES ❑YES. ONO ❑YES CNO ❑YES ONCE PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIOTH LENGTH NO OF LATERAL SPtNHA DEPTH HELOW PIPE FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLO DISTR. PIPE TERIAL NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. DIA ELEV. PIPES DIA: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING URIL LED CORRECT LY VER MATERIAL VERTICAL UFT CORRESPONDS TO APPROVE D PLANS ❑YES O❑YES ONO COMMENTS: RS: LS: NUMBER OF PROPERTY WELL: FEET FROM LINENCE ONO NEAREST 1, Tt~E.~K 13RCi~ ~\Lt~:~ E.x~~i r~{Z 1Z> Z . PQ6?fP_1-y r+r~c ►a1 ~~ia Sq)rj v rAil-3 C . DILHR Leroy Jansky P.S.C.' 13 E. Spruce Street Chippewa Falls, WI 54729 (715) 723-8786 Sketch System on Retain in county file for audit. Reverser Side. SIGNAT E: TITLE DILHR SBD 6710 (R. 01/82) ! L I e~. ,~o.c? ' 1=trod. ~Et~~E llrak~ NC: 'TCl ~cAL~ vv'"-v 1W0 --pf' Y 1C Tip-rJK ~UO 5T . ScAI-E_ 1'.y0 1 i ~ 415 3, I N I 1 I r ! I. a6.z. µaus~ To Sic RCr(}n~K L ewe DILHR SANITARY PERMIT APPLICATION COU T I In accord with ILHR 83.05, Wis. Adm. Code ..4~~.....~...a. STATE SANITARY PERMIT ~3 ~s -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER ^ PROPERTY LOCATION P 716FJ7 /7 - ,(l'/a , S T. , N, R E (o W PROP RTY OWNER'S MAILING A RESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY, STATE ZIP CODE PHONE NUMBER 77 CITY NEAREST ROAD, LAKE OR LANDMARK Q VILLAGE : , T e14-:- II. TYPE OF BUILDING OR USE SERVED: ®c~ - I07Sf- 90-00 Number of Bedrooms if 1 or 2 Family 3 OR Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. [X Replacement c. ❑ Replacement of d. ❑ Reconnection of e. E1 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. yConventional 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. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): j 30 ®1 Feet Private ❑ Joint ❑ Public CAPACITY VI. TANK . Site in allons Total # of Prefab Fiber- Exper. Manufacturer's Name Con- Steel Plastic INFORMATION I New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank ~t3 f ❑ ❑ ❑ ❑ ❑ 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): Plumb 's Signature: (No Stamps MP PRSW Business Phone Number: Plumber's Address (Street, City, State, Zip Code Name of Designer: r 3d X? 6A VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST CST's ADD SS (Street, City, State, Zip Code) Phone Number: E AC,*"nyle -2/5- 1.2 Z - IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) Approved F-1 Owner Given Initial 4/S chary e Fee X Adverse Determination S 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 y TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed .pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage systern, 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. Provide 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; Vl. 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'/ x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundvvate= included the creation of surcharges (fees) for a number of regulated practices which Wiscori,-:en's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried ~reasure is used in your building is returned to the groundwater through, your soil absorption system or the disposal site used by your holding tank pumper. f The monies collected through these ~,.jrcharges are credited to the gr+aundwater fund adminis tered by the Department of Natural F =sources, These funds are used for monitorl:?g ground-- ~ J,,ater, groundwater contamination it+.;estigations and establishment of standards. Gro:and,Irater, = it's worth protecting. SBD-6398 (R,03/86) I r APPLICATION FOR SANITARY PERMIT S T C - 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/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 T4t f- AUK Location of Property Section !~LqT j_ N - R~ W - Township 5j; ~aS t_ .,-7 Mailing Address 'jig Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created I ?Sly Are all corners and lot lines identifiable? 4K Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume 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. PROPFRTY OWNER CERTIFICATION I (We) eenfii4y that a.2,Q. statement6 on fih,i~s 4o~un ahe filule to the best o4 my (ouh) knowledge; that I (we) am (ane) the owneA(,s) o4 the pnopehty debn bed in this in4onmation 4o4m, by vi tue o4 a wak4anty deed neeonded in the 044iee o4 the County Regizten ob Deeds as Document No. and that I (we) ptuentty own the proposed 6 to 4on the .sewage P0,4 6y,6tem (on I (we) have obtained an easement, to nun with the above ducA bed pnopeAty, 4on the con6tAucti.on o6 -6a,i.d bye.tem, and the flame hab been duty neeonded in the 06jice og unty'Reg' o6 Deeds, ass Document No. Llo,6 ) . SIGNATURE OF OWNE SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED z t H . STC - 105 r' r a H SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z d OWNER/BUYER a Pe, rL ~ Ta,e ~'rLF1::SoA i H ROUTE/BOX NUMBER /if ~g Fire Number .CITY/STATE ~SLg/>'IEr1ScTj : ZIP_ 55°6:C S PROPERTY LOCATION:_*W, Section ,?1, T ja N, R__Z_7 W, Town of _5 j, -~7 Se ll , St. Croix County, Subdivision J~(,¢ , Lot number A/,¢- 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. H 0 E 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- It ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoni ffice thin 30 days of the three year expiration date. SIGNED' - DATE St. Croix County Zoning Office P.O. Box 98= Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUSTRY, DIVISION LABOR ANID PERCOLATION TESTS (115) P.O. BOX 7969 HUdiAN FIF-LATIONS 1 / MADISON, WI 53707 6 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MU?VretP*trrY: OT O.:BLK. TO-: SUBDI ISION NAME: 10 1/ Q'1/a a S /T 3o N/R J (Or) W COU T O E 'S NAME: M'A (LING ADDRESS: D SC1 142 '45~, RA ' 4-va5' USE DATES 13 IkTIONS MADE NO, BEDRMS : COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: I Residence ❑ New Replace ij RATING: S= Site suitable for system U= Site unsuitable for system [S CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) s ❑u fKs au .is ou a s u❑ s u If Percolation Tests are NOT required DESIG RATE: rFlrodplain, ny portion of the tested area is in the under s.H63.09(5)(b1, indicae: indicate Floodplain elevation: PROFILE DESCRIPTIONS a CQ I BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER ELEVATION OBSERVED EST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ,-1015 of 17 -75- S. 13P 0-0 B- 2- 1, 1. l ad n. . J~ k3 47- 4'x 0ow t ob RQV B- B- B- f)AA %A1 PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 4"01!Eg AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERIOD2 P R D PERINCH P- 3 P- Z' _3 too InYlp P- Z.[PP-P PLAN: Show locations of percolation tuts, 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 / 61 -74 I ~ 3 F 5 = F f "+b5~ SID - 1 +0 i ? _ r_m 3 1 _co I ill T_.._ - - •~q s , el 1 t z I 3 ' i 3 ( I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): 0,4!n~q ~ As TESTS WERE COMPLETED ON: ~c., &-jam Qlr, ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): ~ ,15 Z a 919 7/.S"-2 f to ~ to use CST SIGN T1J DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - d INSTRUCTIONS FOR COMPLETING W 115 - SBA? - 6395 To be a complete and accurate soil test, your report MW' 1 . ornplptp ' it description; 2. The us,. rust clearly' ~rether this is corn.ne , 3. NI.. o' or commercial use I 4 _ 5 A F)IteG TANK ONLY IF ALL ~s ,rnd completing the plot plan; 7, wing to scale is preferred. A own, are e permanent; s as t- dast exemp- 1 ood plain, e' v, r t' )x; it current addrE c< 1 stribute as r J~ T_ti WITH THE r' `ITNIN 30 DAYS G, 7TIC1l . "-IATIONS F C- ° 'IFIFI SOIL So r 10") 1011) der 3") I : - Li _ x. s s sl *cl z ` i { :,e Department may request ref nlin.z fnr the private y to /Rom v el Q oc - ~ _~ys~-~,~y cis iai1• NO TE Iviv g W /1C/~/ 1, C 1j-7eo 1 7r jS )(3 wji-L 43&-r ~a C-41- yv~ tXl5r j1 d V~ I _ N _ Y Doiv c T, ~ rr~~o2 cSQ~yi~=/aSC T ~.l Wisconsin Department of Industry, INSPECTION DILHR Labor and Human Relations Leroy .lansk Safety&AvldingsDivision REPORT Y P.S.C; Bureau of Plumbing„ 13 E. Spruce Street Inspection Da e Chippewa Falls, WI 54729 lv 2 (715) 723-8786 Name of Premises Addrecc,o< Legal Description GOYFTownship County ~Rc, sc,N - ~ StDlcACE. ►~w, n1W , D-£,, 30, tCtW SZ . JGS~A1+ SN- ,crypt Master Plumber Name and Address x Master Plumber Firm Name and Address Plan I.D. No. 4.c'~N~t/I4 SC~.1MtY't R+ Z Pc-,1, 2-9S 'S01A%P~SQ", WI 5 4UL S Sanitary Permit No. oiI Testes 83x5 Licensed Persons Name(s) and License Number(s) s t_. Sc. `Nt,~~ "Owner's Name and Address MPRS_603aos' Sc1w~ Ei' w-t SyC~2.S VIP` Io 0 lW i e F Page --Lof Signature of Responsible Licensed Person (only one needed) /Check all Signature of Plumbing Consui Private Sewa a Co tant Original: Copies to: ithatapply~ SsD-6192 (R. was) District X_DILHR 0 Plumber O°,-" ner County/Lo s s Other .