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HomeMy WebLinkAbout002-1015-20-000 s r~ 0 cn0 3vn C7 (D -0 c I ~ O O TI 'I W O O 0. O N C O ^ v N m 3 O A T a IV ~I O CL Z a N V Z'I CD co a) CD a) co Cil N a 7 O O N j -1 CO N C) CO CD CD CD 3 co 7 ° 3 w v ! o ~ o v (D x CD fn D n CD cfl y N ou CD 3 a 0 Q-0 CD C) K) N co to N .c r. c °~0 000', !mil 2 n OI o~ CA ca ch CD acF q om o ~vo'C m _ m U) N a C 90 N Q N O!' C CL 3 N ai z 0 0 O D D o CL !r o CD c I w m a 3 Z CD I ~ z A o N ' ~ M 0 a z G1 Z .i W N cD p rV z Cl) I ~ m CCD a W m o a CD 2.9 a rn g a: a :3 T SI) a o N I o v m n s y m ao I cr ~ a ~o y tv N a 14 O b N 7 69 P O ti O CL ti Parcel 002-1015-20-000 07/31/2006 12:44 PM PAGE 10F1 Alt. Parcel M 07.29.16.98A 002 - TOWN OF BALDWIN 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 - HOLLE, DOUGLAS D & MARY E DOUGLAS D & MARY E HOLLE 1031 HWY 63 BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1031 HWY 63 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE SEC 7 T29N R16W PRT N 1/2 SW 1/4 COM 208 Block/Condo Bldg: 1/2 FT N & 836 FT W OF SE CORNER, N 230 FT, W TO W LN, S ON W LN 230 FT E TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) POB, TOWN BALDWIN 07-29N-16W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 726/475 07/23/1997 710/318 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 11/02/1999 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.500 9,700 106,500 116,200 NO Totals for 2006: General Property 2.500 9,700 106,500 116,200 Woodland 0.000 0 0 Totals for 2005: General Property 2.500 9,700 106,500 116,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 510 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 p fn d O c <p 0 CD CMD 13 M 7! 9 3 \ 1 n O v y O coo T DW7 OV OO QQ~~ • CD 7 O CCD CAD .p C1 N) ICI (O CL FD Z p. ^ y V Z O Nab o M td %.o W H °o o m o 0 00 0 O N A a O H G ~d m 3 rD o O 3 r%1 D] CL r. 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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner DOUGLAS D & MARY E HOLLE O - HOLLE, DOUGLAS D & MARY E 1031 HWY 63 BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es) : Primary Type Dist # Description ' 1031 HWY 63 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE SEC 7 T29N R16W PRT N 1/2 SW 1/4 COM 208 Block/Condo Bldg: 1/2 FT N & 836 FT W OF SE CORNER, N 230 FT, W TO W LN, S ON W LN 230 FT E TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) POB, TOWN BALDWIN 07-29N-16W Notes: Parcel History: Date Doc # Vol/Page T )ie 07/23/1997 U -6/4Z5 lS~ 07/23/1997 710/31 / , 0 /'/Ytta 2005 SUMMARY Bill Fair Market Value: Assessed with: 86674 181,000 Valuations: Last Changed: 11/02/1999 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.500 9,700 106,500 116,200 NO Totals for 2005: General Property 2.500 9,700 106,500 116,200 Woodland 0.000 0 0 Totals for 2004: General Property 2.500 9,700 106,500 116,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 510 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 45.00 Special Assessments Special Charges Delinquent Charges Total 45.00 0.00 0.00 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. 7 TN-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 - SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 hi©° 4 f O scPf~C_ Arret, Sn~~ Gc~el! INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used lZS O/Z 07)C s~ r, ter, Elevation of vertical reference point: '/0c5l , Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: n,~ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side, Rear, 0 feet .t . 11 From nearest property line Front,OSide,0Rear,~ feet Number of. feet from: well building: _/U, (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE f pM CHAMBER z~,~e -S Liquid Capacity : Manufacturer: ' Pump Size Pump/Siphon Manufacturer: hl, pump Model: .SP YO Elevation of inlet: Bottom of tank elevation: Gallons per cycle: pump off switch elevation: Alarm Manufacturer: C7o1rn- Alarm Switch Type: _/~er'GUrtl Front O Side, Rear•,~f~ Number of feet from nearest property line: i Number of feet from well: ~r- Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Length: 7 ~ Number of Lines: --.w Area Built: -576 Width: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: SS / (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: meter: Liquid depth: Bottom o ee ag levation: AiZea Gilt: 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: p ty: Number of rings used: Ele i n o ttom 'of tank: Elevation of inlet: Number of feet from nearest prop rty lin Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of.feet from nearest road: Alarm Manufacturer: Inspector: Dated: 5 Plumber on job: License Number : 3/84:mj r i DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS DIVISION PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969 MADISON, WI 53707 El State Plan I.D. Number: CONVENTIONAL u ALTERNATIVE (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ® Mound 8503611 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: First National Bank 990 Main Street, Baldwin, WI 54002 tSt ELEV.: CST REF. PT. ELEVBENCH MARK (Permanent reference poinH DESCRIBE IF DIFFERENT FROM PLANNW SW, Section 7, T29N-R16W, Town of Baldwin P[e~rmit Number: Name of Plumber: MP/MPRSW No. County: 67647 Dale E. Hudson 6629 St. Croix SEPTIC TANK/HOLDING TANK: WAR MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: ROVIIDEDLABEL PLOCKING ROVIDED OVER 4 L YES ❑NO ❑YES NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING VENT TO FRESH AIR INL ALARM: FEET FROM ❑YES ❑NO ❑YES ❑NO NEAREST--- DOSING `7~ COVER CHAMBER: MANUFACTURER: BEDDING: LIQUID QCAPAC'ITV. PUMP`M/OD~E14 N ANUF AC tUR ROVIID DLABEL lVn~] YES ❑NO U aO r'' fi C [YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERERY WELL BUILDIING TOTRESH AIR IN~_E. (DIFFERENCE BETWEEN FEET FROM r~ NEARFST-10 PUMPONANDOFF) / J' SO YES uNO l ,H: DIAMETER. MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN Z the soil is dry enough to continue.) CONVENTIONAL SYSTEM: uoulD BED/TRENCH WIDTH LENGTH TRENCHES DISTR. PIPE SPACING COVER TERIAL: PIT INSIDE DEPTH. DIMENSIONS PROPER WELL BUILDING: VE TO FRESH LINE. AIRNT INLET GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL- PIPEDISTR. NUMBER OF BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END FEET FROM NEAREST 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- meets the criteria for medium sand. TIONS MJEASURED. DYES ❑NO -PERMANENT MARKERS. OBSERVATION WELLS. SOIL COVER TEXTURE: t~~ YES ❑NO I YE&I ❑NO SODDED. SEEDED MULCHED: DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. CENTER: / EDGES i YES ❑NO ❑YES NO YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE ` TRENCHES: Q -Ile DIMENSIONS 7QY) !V MANIFOLD PU P MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATE~AL & MARKING. ELEV.: ELEV.: DIA ELEV.: L~ P PEIS DI A.: / ELEVATION AND 1bl DISRIBUTION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED T INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY PLANS: PERYES ❑NO DYES ❑NO ` MAN ENTMAR KEF OBS ERVATION WELLS: NUMBER O~F ~PROPERTY WELL: BUILDINGCOMMENTS: FET FROINE: V YES EINO ES ❑ NO NEAREST 10 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE:-~ TITLE: " DILHR SBD 6710 (R. 01/82) .•nki..'. wIeCons', APPLICATION FOR SANITARY PERMIT DILHR PL COUNTY OEPFlRTMIEnT B 67~ UNIFO!jM ~jSANITARYY PERMIT #F' 11 InDUSTRv,w®ora6HUMP1nRELFlTIo nS mum -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNS MAILING ADDRESS ~i'~ s G► f f JrSrl.~ PROPERTY LOCATION ' d 114.,5ed114. S T,?J, N. R It (or W TOWN OF: 47 ldtJ,` LQT NUMBER 6F0-CK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. 3 ❑ Public (Specify): THIS PERMIT IS FOR A: 17-1 New System ❑ Tank Replacement ❑ Repair X Replacement ❑ Revision ❑ Privy Alterna ~ t e System ❑ Re connection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. D Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ ault'Privy ❑ Pit Privy Existing, For Which A Previous Permit Is On File, Permit It issued An Existing System That Has Been Inspected And Is Co iant As F r As Soil Co tions. Total *of Prefab. Site Gallons anks Concret onstructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump Tank/Siphon Chamber -1 L~~ Holding Tank capacity Manufacturer. IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ~ Mound C] In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic 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) 3-75 3 7&1 -XPrivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatu MP/MPRSW No.: Phone Number: Plumber's Address: / Name of Designer: Dp Dale_ L& W _-w COUNTY/DEPARTMENT USE ONLY *Reason a of Issuing Agent: F e: Date: ❑ Disapproved S f) ❑ Owner Given Initial & [ - t Approved Adverse Determination or 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 Q)c ? I • k k~ N I i, kw y! g 1 r ~ C., t1 ` ..`FhQ? h `k. { - Cyr ~~t.~•1 Alo C y S n fA Ul N p ~ CA Al ~ ~ O fD ~ ~ O O a ° 'c to ~ w ° rv 1 =r 3 Q O C O C_ < 7 3 C (O (O p mo :N (D .0 CD (a CD a* - to (DD OR 0 AO ~ (D ~ N m CO 0 91) CD a 7 m (D O Cp A 3 a OC.) (p fD W O'D O N tO = Al O 3p0 ,p<~CC3 vi C 0 a AO Z to a Q O O ~1 C N f (Q~p p O O r O a 30 i ° w ° -coo-.vv c0 ° w is (D c mv~i-NC. O DSgm- G) 0 =r o Q C 06 Q :3 N .0 1~ °N(D Nm~L' Z D ° v, w ~Q G Z ° ? pa CO) Q w o °N CD O~(ADC=D?Q. D -I s a(DA 3~° co (D C 0 ? m °a ,..wzow° M ~ sr CA ID =r C CD 3a C30 M V vi a acs*m C X11 = ° o v (D et S -i ~ M d a O N = CD C = o cD w vi n cl. o ~ 3 T. V O D C C-D (;v a uCic0awo m 9 0CD COL m 0 6 aErr N Q 7 a CD ~uro G)~~ <N~CD~o g A N 1 CL O j C co W C -1 h C ~D 0 06 C=D 00 ° 3 ° o - CD • z o cm \ 0.a n °y ~,•v ~ ~a ` M `fit, a d _ t, d UJ A j . Co. W c-a" ~J cj (5 cc ter) fi. 1 t;`~ x c 3 .;t eta ..,z 1,5 "-15 ~y t3 c N. 4 L)FA R-T ENT OF REPORT ON SOIL BORINGS AND SAFETY & INDUSTRY, DIVISII,.. .I LIMAN AND PERCOLATION TESTS (115) BOX 3707 l > / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: r~ p TOWNSHIP/ OAT/NO.:BLK,./~NO.: SUBDIVISION N/AME: 414) 1/45'J/4 -7 or COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ❑ New gReplace RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptionaq DS DU OS DU ❑S CU OS IRU ❑S 2U z,vI If Percolation Tests are NOT required DESIGN RATE ny portion of the tested area is in the under s.H63.09(5)(b), indicate: L indicate Floodplain elevation: AO PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH Mg. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) / /77e f a 'r B- 5i5 AW11i o 17 e, so" 5.-,~ / spt• 5 s- 7.3'3 161, a-Y > 733` -5:5 " al) S B- 3 j?> o "0 151o ` F B- B' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER WELLING INTERVAL-MIN. PERIOD t PERIOD 2 P R PER INCH P- P_2 .30 P- 3 1316 /Y1, Ile f i 3 - 3 P- ?0 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 /o2 • sy ` 850, ~ I Ir r~ SEC , I i E I J_ 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: CERTIFICATION NUMBER: JPHONE NUMBER(optional): CST SIGNA/Ty/]q E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. -6395 (R. 02/82) - OVER - Page Of Straw, Marsh Hay, Or Synthetic Covering Medium Sand Distribution Pipe Topsoil _ c 3 E D PLUHr3ING % Slope i, ('o 1j, Bed of Zy- 2 (Force Main Plowed Aggregate From Pump Layer DEPARTMENT OF - U ~uST,tL Q / y t EiiVIS6OC4 Oc RELATIONS ~-`L'INGCross Section Of A Mound System Using E - 6- . SLR C~SpO~ Bed For The Absorption Area F v 75 UENCE G _Z10' Signed: A ?,0-Ft. H B 7•n Ft. License Number I 9'a Ft. Date: /-~5~ J 7= Ft. K 16,0 Ft. AlternateefPosition L Ft. Force Main W 25'x/ Ft. 85 03611 L t Observation Pipe--,,,, 1 ~ K A 1~--------____ W I - --r- ~ Force Main j From Pump Distribution Bed Of - z 2 Aggregate Observation Pipe Permanent Markers LA-~ - 0 RECEIV8D Plan View Of Mound Using A Bed For The Absorption Area II IN 2 6 1985. PLUMBING BUREAU Page _ Of _ Perforated Pipe Detail End Vie, )Perforated End Cop] i PVC Pipe a ~c% Holes Located On Bottom, K'' Or°'~ S Are Equally Spaced S * ?C PVC Force Main 4 PVC MonifQld pipe ' Alternate Position Of Distribution Force Main Pipe Lost Hole Should Be Next To End Cop End Cop Distribution P+pe Layout P ;23 Ft. R lv ,U f 7". f~ S 3a0 y; X ,3C7 Inches Y 1_ZInches Hole Diameter Inch Signed: i( i-- Lateral Inch(es) License Number: N/P ::~l,e•9 Manifold Inches Date • Force Main 3 Inches # of holes/pipe- PLUMBING `Invert Elevation of Laterals., Al Ft. Conditional it, rft awn, JTA~k r~ . RECEIVED DEPARTMENT OF INDUSTRY, LABC!R AND HJ AR RELATIONS DIVISION Or SAFETY AND BUILDINGS ,11 IN 2 6 Mq iESFONDEt~CE PLUMBING BUREAU SEE COF~~~ PAGE OF PUMP CHAMFER CROSS SECTION AND SPECIFICA IO~ T ~ VENT CAP `1~\a~~ 4"C.I. VENT PIPE ,V`" APPROVED LOCKMIG WEATHER PROOF JUUCTIOM BOX MANHOLE COVER r 25'r FROM DOOR, i WINDOW OR FRESH I"MIAJ. AI. iN T AKE GRADE } IB"MIA1. COIJDUIT - IAII_ET PLUM1 .r PROVIDE I I TIGHT SEAL ~Oi1~6~Li',+~ I I I APPROVED JOINTS APPROVED JOINT A I W/C.I. PIPE W/C.I. PIPE EXTENDING 3' vi I 1 ALARM EXTENDIAIG 3' O►JTO SOLID SOIL PARTficfJT 0F Ifi,~OcTR j ( I I ONTO SOLID SOIL DIVISION OF i Lr All J I I NNE! rPELATIOhS I 1 ShF1 Tt 1~(i~1 ttUsi_(.AGS I ON SEE C 3RPIE$P NDEA,'", ELEV. FT. PUMP-, J OFF D CONCRETE BLOCK RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HA,S~ tru g6CIAl SEPTIC -5 PECIFICATIOKIS *}l~~ u DOSE TANKS MANUFACTLIRER: Sr.de-e- eS IJUMBER OF DOSES: J PER DA4 TANK SIZE: moo GALLONS DOSE VOLUME ALARM MANUFACTLIKER: Pa INCLUDING BACKFLOW: GALLONS MODEL AIUMBER: CAPACITIES: A= g°~ INCHES OR 12-151GALLOQS - GALL~IJS SWITCH TyPE: 19.S 8 =--INCHES 0 7Cca o PUMP MANUFACTURER: //y j5k? INLH~ OR GALLONS MODEL MUMBER: D- 12 204 GALLONS SWITCH TYPE: MOTE: PUMP ARID ALARM ARE TO BE MIMIMUM DISCHARGE RATE Uk/yGPtA INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEIIJ PUMP OFF AND DISTRIBUTION PIPE.. 91?3 FEET RECEIVED + MIMIMUM NETWORK SUPPLY P.$ESSURTE//.. . . . . 2 S FEET + ,~o FEET OF FORCE MAIN X ~ Fzlpp FtFRICTION FACTOR. ~ EET .II IN 2 6 1985 TOTAL D~IWAMIC HEAD FEET PLUMBING BUREAU r i lara?e s 7 CJ IUTERNAL DIMEWSIOWS OF TAIUK: LENGTH ;WIDTH - -;LIQUID DEPTH `~7 SIGNED: LICENSE DUMBER: M p eGl DATE: ~~~y 5 24 ~i 1 . ~~,y • - } 90 12 z+ 4 ,,rte . y 0- 16 32 40 . 64 80 ge 112 Us . QAL.ONS PIER MINUT9 S Mead,Capaciq► 1l4A af"t S 5i11 Submersible Residential Sump Pumps Max. 904* SYQA, 14,SVK±;II, 2„ S • 4 Pole 90 . s -HANDLING C0^1 211 SUB 24, 5LE all 20 oil .I1.. - S -GE 26 EWA 16 EFFLUENT S 4 M 100 120 140 160 a., a L.S• NS PER MINUTE + k Mead-Capack Y: I SSA and M Suhmeerslbie Sump Pumps 9` K f" r ; Max. Sod lA," S $P1, i 1„ Spheres, RaiFj '17 RPM t 40 .32 24 20 i - { . I O 12 rt< , 4 a 0 .20 40 AKI 80 100.. 120 10 160 U.t. Ci~~QNB p®i M~11J'fE YealKapacily: SKM, SK75 and SK10A Submersible Sewage Pumps t OW2 IPM Lf`ADivis7on of 1Nyl6in, Inc. ,Y WDRoC3wMF:MC PUMPS Pb* Oft* Bops 327, 419/209 3042 ! ►WWOW a B.nsy POO& AOW4nd. ONo 44906 aM.ft WOMM 0M." "a ISO I a e~nra►. orn..a e~► +c~ BIB j r KSHEET - MOUND SYSTEM DESIGN PROBLEM, Design a mound system for a The site characteristics are. Depth to groundwater or bedrock 147 in. Landslope Z % Percolation rate 0_ min./in. Distance from dose chamber to distribution system .920 ft. Elevation difference between pump and distribution system 9°ft. Step I,' WASTEWATER LOAD = gal. Step 2. SIZE THE ABSORPTION AREA A) Area required r 3-15- - sq. ft. B) Bed or trench length (6) _ q7 ft. C) Bed or trench width (A) _ Q 85 . ft. D) Trench spacing (C) W tew ter 19Ad .24 gal/ft2/day 6 _ IVA ft. nc hes Step 3, MOUND HEIGHT A) Fill depth (D) _ ft. B) Fill depth (E) = D + t slope (A) ft. C) Bed or trench depth (F) ft. 0) Cap and topsoil depth (G) ft. E) Cap and topsoil depth (H) _ 5 ft. RECEIVED IN 2 6 198-S PLUMBING BUREAU 3 Stop 4. MOUND LENGTH ' / A) Erin slope (K) (p + E) + F + H x 3 = JQ ft. 3 B) Total mound length (L) B +2(K) / c0 f ft Stop S. MOUND WIDTH M Al) UpsloPe correction factor A2) Upslope Width (a) ~ (D + F + 6)(3)(factor) • ~ ft. 61) Downslope correction factor 82) DOWnslope width (I') _ (E + F +'G)(3)(factor) .,.._.3,,. f t. C1) Total around width (W) for bed J + A + I . 25.1 ft. C2) Total around width (W) for trenches J + + (no. trenches -1)(c) + A + I ft. Step 6. BASAL AREA 8503611 A) Infiltrative capacity of natural soil = -74 gal./ft2/day B) Basal area required R wastewater flow i natural soil infiltrative capacity L, sq. ft. C1) Basal area available for bed for sloping sites = x (A + ) _ 9 13-1 ft. C2) Basal area available.for trench for sloping sites = B Wi J+ sq. ft. C3) Basal area available for trench or bed for level sites B x W RECEIVED 2' sq. ft. JUN 2 6 1985 PLUMBING BUREAU q"WiNk"W", 4400 St", DISTRIBUTION SYSTEM 7A) SIZE DISTRIBUTION SYSTEM 1) Hole size in. 2) Hole spacing _ 3) Distribution pipe length *4) Distribution pipe diameter in. 5) Spacing between distribution pipes in. 5) Distance from sidewall to distribution pipe in. ,.7 78`) DISTRIBUTION PIPE DISCHARGE RATE ft. 1) Number of holes per pipe 2) Flow per pipe _ l_ GPM 7C) SIZE MANIFOLD 1) Manifold is central/ end 2) Manifold length' _ ft. 3) Number of distribution lines .4) Manifold diameter in. 7D) SIZE FORCE MAIN 1) Minimum dosing rate: GPM 2) Force main diameter = 3 ~ in. 3) Friction loss 79) TOTAL DYNAMIC HEAD 0 1) Vertical lift ft. 2) Friction loss 3) System head 2.5 ft. ft. 4) Total dynamic head t. RECEIVED .II IN 2 6 1985 PLUMBING BUREAU y 7F) PUW SELECTION j I) Pump selected will discharge 3r/ GPM at ft. total dynamic head. 2) Pump nodel and manufacturer 7G) DOSE VOLUME 1) 10 times void volume of distribution lines gal./cycle 2) Daily wastewater volume = 4 doses/24 hrs. gal./cycle 3) Minimum dose volume 71, al./cycle 7H) OOSE CHAMBER 1) Minimum capacitor required gal. t ~L X2(0 ()BCD RECEIVED ? F 1QR~ PLUMBING BUREAU D I L H R Safety and Buildings Division PLAN APPROVAL Bureau of Plumbing P.O Box 7969 ❑ General Plumbing Plans Madison, WI 53707 Private Sewage Plans Telephone: (608)266-3815 6 7 (9 I Plan Idcntific'Ition No- Per ay mw~ _ 4S7 ~ ^w 'f t,r a T PRIORITY PLAN REVIEW ONLY Plan Review I ee heceived Petition for Variance Fce R(,( Project Name Project Location - Street No. or Legal Description r ca - s 1... `_t - w ! County ❑ City ❑ Village CX_Town of: - .y,,,}no, J .,~osz VS The plumbing plans and specifications for this project have been reviewed for compliance with applicably code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditiohally 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: 3a 3b 3c 3d 3e 3f 3g 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: (1) (2) (3a) (3b)t (4a) (4b) (6) (7) a This approval will expire two years from the date approved be ow or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only. All other system reviews must be submitted to the Bureau of Buildings and Structures. Comments: By: James Sargent Bureau Director If Questions Pl, s,Approved By: Date Approved: . ` r Contact r. lz~ cc: f."Private Sewage Consultant ❑ Plumbing Consultant ❑ Environmental Health County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/85) ❑ Owner ❑ Other 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/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 The First National Bank of Baldwin Location of Property _/Y,/V Section _7 T N - R W Township ZGY [tJi 22 Mailing Address 99o c~rli 5~/Ua~- J~ Subdivision Name Lot Number jg , Previous Owner of Property "y,*7e 71 Cam/?/ 5- Total Size of Parcel Date Parcel was Created r Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes No Volume 710- and Page Number -3f65~' 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 1 (We) eeAti6y that att s.ta temente on this 6onm ane tAu.e to the be6.t o4 my (oun ) knoweedge; that 1 (we) am (ahe ) the owneh (s) o6 the pnopen ty ded eh i,bed in xhiA in6o4mati,on 6onm, by viAtue o6 a wahha.nty deed neeonded in the 066ice o6 the County RegiA ten o4 Deedd a.6 Document No. p /33,2 ; and that I (we) pees en tty own the p4opos ed .6 to bon the sewage diAposat s yA tem (on I (we) have obtained an easement, to nun with the above descA bed pnopenty, bon the const4uction o6 said system, and the same has been duty neeonded in the O66{ee o j the unty Reg.is.ten o6 Deeds, at Document No. ) SI ATURE Qi/OWNER Assist. Vice-Pres. SIGNATURE OF CO-OWNER (IF APPLICABLE) 8-27-885 DATE SIGNED DATE SIGNED H z H a ST C- 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a OWNER/BUYER The First National Bank of Baldwin ROUTE/BOX NUMBER 990 10ain Street Fire Number CITY/STATE Baldwin, WI 5402 Z I P 5ZI 00 Z PROPERTY LOCATION:/W ~4, _5 y k, Section T ,Z9 N, R 14 W, Town of 12St. Croix County, Subdivision 4 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. H 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ~v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning 0 five within 30 days of the three year expiration date. SIGNED sist. Vice-Pres. DATE 8-27-85 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. • j SBD 6678 (R: 08/83) (Plb 100a) (Wis Stats. S. 145.02) Detach And Return Upper. STATE OF WISCONSINDILHR DIVISION OF SAFETY & BUILDINGS Portion Qf This Form With .f 6 7 BUREAU OF PLUMBING 201 Any Return Correspond P. E. WASHINGTON AVE: RM 141 O. OX 969 MAD BSON7 W153707 O 608-266-3815 DATE: 08 1 PROJECT: Kanis, Wayne Residence 2 4a(g) NW,SW,7,29,16W Boldt's plu lb#rlg. To Baldwin St. Croix WI 820 Main Street Baldwin, WI 54002 PLAN ID. # 85-03611 DETACH HERE PROJECT NAME -Ka"' S' Wayne Residence PLAN ID. 85-03611 - # This is.to acknowledge receipt of your plans and specifications for the above.-.indicated project. Preliminary review indicates the required fee is $ 80-00 Fee Received is 80'00 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 beheld in abeyance. 1. Plan Submission ❑ Soil boring and percolation test data on 115 completed ❑ Additional informati®n shall be submitted in duplicate unless by Certified Soil Tester. (I-copy) - specifically noted. ❑ Petition For Modification signed by county, owner and ❑ Plars not clear, legible or permanent, notarized. (1 copy) ❑ All information submitted shall be signed, dated and sealed or -stamped in accord with Section ILHR 83.08 2 O a El Complete data.. relative to anticipated use of building. 4 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. II. Pressure Distribution Systems (Mound or Inground Pressure El Holding tank agreement signed by owner and local ) 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 onsite 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) ❑ Affidavit 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 data. pump(s) or siphon{s). ❑ Construction details of septic, holding or dose tank if site VL ' terns 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. SBD 6678 (R. 08/86) (:Plb 100a)'(Wis Stats. S. 145.02) ~ ~ { J STATE OF WISCONSIN DILHR Detach And Return Upper DIVISION OF SAFETY & BUILDINGS r Portion Of This Form With BUREAU OF PLUMBING I 201 E. WASHINGTON AVE. RM 141 Any Return Correspondent P.O. BOX 7969 MADISON, WI 53707 608-266-3815 I Fo DATE: 06/26/85 IpN~N 1,ggs PROJECT: AFFj JCanis, Wayne - Residence 4a(g) 61 NW,SW,7,29,16W Tn Baldwin Boldt's Plumbing St. Croix 'WI 820 Main Street Baldwin, WT 54002 PLAN ID.# 85-03611 DETACH HERE PROJECT NAME Kanis, Wayne - Residence 85-03611 j PLAN ID. # This is to acknowledge receipt of your plans and specification for the abaete-indicated project. 80.00 Preliminary review indicates the required fee is $~0 , Fee Received is $ 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. /EW I. Plan Submission ❑ Soil boringand percolation test data on 115 completed ❑ Additional information shall be submitted in duplicate unless by Certified.SoitTester. (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 i Section ILHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required- 0 copy) Administrative Code ffidavit 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. ❑ bolding tank agreement signed-by owner and 16e4 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 onsite 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. 1 Certified Soil Tester. (1 copy) ❑ Affidavit tot 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. Violation Number Form - S T C - 101 PRE SANITARY PERMIT ISSUANCE PROCEDURE Location Section Township/Municipality Lot No. Blk. No. Subdivision W1 JR/ Procedure prior to sanitary permit issuance where a septic tank must be replaced, during winter weather or other health emergency and soil evaluation or other Sys- tem evaluation cannot be conducted. 1. Obtain assurance that the property owner is aware of further requirements for a system evaluation. 2. Obtain assurance that owner is aware that if system is found to be failing, it will be their responsibility to replace it with a code complying system. AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY PERMIT: I, The First National Balk Of Baldwronthe undersigned do hereby acknowledge that I am receiving a sanitary permit to instal new septic tank without a soil and system evaluation due to inclement weather of health emergency. Furthermore, I acknowledge that a soil and system evaluation will be conducted as weather permits and that if the system is then found to be failing as defined in Section I L H R 83.02 (18), Wisconsin Administrative Code, it will be replaced with one that complies with Chapter I L H R 83 of the Wisconsin Administrative Code. If temporary pumping is to be utilized for maintaining a newly installed septic tank, due to failure of the system, the tank shall be maintained by a licensed pumper in accordance with N R 113, Wisconsin ministrative Code. SIGNED Vice-Pres. DATE 7-17-8 A copy of an affidavit in lieu of EH 115 along with the PLB 67 must be submitted to the Plumbing Bureau for purposes of fee reimbursement. Zee AVP.7-17-85 i ature o Applicant Date Subscribed and sworn to'before me STATE OF WISCONSIN This 17th day of July 19 5. SS. COUNTY OF St.Croi.N Notary Public, State of Wisconsin NOTARY WC • = OF Itl My Commission Expires: Dec. 6,1997 ST. CROIX COUNTY r s ~~'k WISCONSIN ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 June 24, 1985 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the First National Bank property, located in the NWT of the SWI-4 of Section 7, T29N-R16W, Town of Baldwin, St. Croix County revealed suitable soils at a depth of 47 inches, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincer y, Thomas C. Nelson Assistant Zoning Administrator mj STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township/"0Wt*CV0bgM NW 14 SW 34 S 7 T 29 N/R 16 XMMW Baldwin St. Ctoi,x Street Address: Subdivision: County: Landowners Name: Mailing Address: First National Bank 990 Main, Baldwin, WI 54002 I (We), the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises.are not suited for a conventional private sewage system. If approval is granted, I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for-the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. &Ignature of Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY OF This day of 19 Notary Public, State of Wisconsin DILHR-SBD-6413 (N. 05/81) My Commission Expires: WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St. Croix Location = 1/4, sw 1/4, Sec. _7 T 29 N, R_Lfi__E (or) W Town Baldwin Street Address Lot No. Block Subdivision Landowner's Name: First National Bank The application for this site is for: ❑ new construction use. ® replacement system use. If this is NEW CONSTRUCTION USE, the alternative private sewage system is: ~..1to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota num ers-i e3 to you.) ]one of the applications needing a quota number. The quota number assigned to this application is for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. for an individual lot for which a sanitary permit unsuitable due to new or changed soil crteria s establdishbut ed bystheter department. (....]for an application on file prior to February 1, 1980. Llfor a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: Qa failing conventional soil absorption system. ❑ a holding tank that was installed and in use prior to February 1, 1980. ❑ a privy that was installed and in use prior to February 1, 1980. If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a conventional private sewage system, check here. I certify that the above information is true and accurate to the best of my knowledge. Name Thomas C. Nelson Si ure (County Official Title Assistant Zoning Administrator Date June 24, 1985 DILHR-SBD-6158 (R 12/82)