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HomeMy WebLinkAbout030-2066-70-000 0 cn o ig v n r~ 411 ~ n 3 r ry m CD a s: v N c1 j m _ Cn 2 cn O O Z Cn W O • n wr (C7 cn cn o ° ° c ° m co cD ° , co m 0 o N - m N cc) 0 N O N O 'O 5 L O r m 7 O (D 0 C) 0 C, -u -0 0 O O O C(D c~ CO J (.71 _ O W 0 !S. 0 = 7 V E: j O O N C QO O .7 d N L < D m fl- 0 e G D O O O A z j C" (.0 co O Co .0 ~j O C 41.4 (D ^ a "46 'O (D ~%1 s o o o * 1144 D _!'y N -a ° fY,4r _0 N N N N v cr v v o F ~ o _ m a N ° 0 D 7 3 ~ cn - a m 7 fn N O _ Yk CC A ° D D o N c "~r O C~' ~ 7 A N NO (il T d O_ h~ O O O CJ ~A O V ° A Z n co ~b _ A Z O 0 G7 W co - O W cn CD A O CL Z 0 o 7J ° N 3 A ° n Z m W ~ v N "O O CL °003 d s d p. C cn( N Z3- W (ap 7 O Z Q cn ~p d O v O g a 3 m O N N O n 0 0 {p O (D (D ti 7 cn v O CD 0 ~ ~ a cn (D p' 7 ~ 7 V 7 n p N? 7 N CO (D 7" n 0 J^ ~ 7 7 O ~ O d 7 3 m' (D CD ~ C N O w ;A O tv ffl n ^ O C 3 r ~ , n 1 V> It r ~ (n Rr r' 0 1 G o m 4A V) n 3 a r• w ~ A S 1 It- DAN D as < }j 3C)! 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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 JOSEPH M & JOANNE M NORELL O - NORELL, JOSEPH M & JOANNE M 195 RIVERVIEW ACRES RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 195 RIVERVIEW ACRS RD SC 2611 SCH D OF HUDSON / Vv SP 1700 WITC Legal Description: Acres: 1.810 Plat: N/A-NOT AVAILABLE SEC 35 T30N R20W PT GL 4 COM SE COR SEC Block/Condo Bldg: 35, 1817.88 FT, S 85DEG W 213.54 FT WLY 9 L'Y~J9$ FTC Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 11 DEG E 298.64 FT, S 23DEG W 351.5 FT N 35-30N-20W 88DEG E 50.3 FT N 47DEG E 188 FT, N 40DEG E 148 FT, N 17DEG W 263.2 FT, N more... Notes: Parcel History: Date Doc # age Type QW_3/1997 726/49 l~ 7 07/23/1 7 2005 SUMMARY Bill Fair Market Value: Assessed with: 84663 338,500 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.810 101,400 206,500 307,900 NO Totals for 2005: General Property 1.810 101,400 206,500 307,900 Woodland 0.000 0 0 Totals for 2004: General Property 1.810 101,400 206,500 307,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 115 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 n y O m v n r_ d o t7 vj o c ~D CD c o A 3 1 3 >v O Cl) o v vN tl ° rn o C/) w °w 0 `C v. c 0 CO is ° r- s a :3 n c: (n co m N ° No c co m OD C- CD No m 1 N d w O N cn cn 3 rn Q (D O ° O O CD 0 '0 ' c 7CD o W M ::r o ° cn 3 ° 3 N 7 O lV o '."I. w O W CL 7 D ° En W c 0 c _ m 3 rt K V i q~ N O O W G O z 8 8 V G G a o on on N o c < 0 ;2 Z -x..✓ Z 0 0 0 rt H _ O fn tR !n CD N < ON rzy ° v vaam ~o f ° L7 v °w FD. N <o = i CL m c CL m 3 o N CL N H C . Z o D D o O 7> v O Z r- a• CD ° j . r- :3 rn r CCD O c ~ _ I ao w m i N CD 9 H Z p Z CD Co n O N t?] O , n crt ri (n j z: Z O (D fD Z Cn v O m C1 I tT] o G7 r O U) W T o o O N G Z rt n 3 r 70 N rt o - o W H H. o 'L3 N O O 3 z W Li N• O Ul (D Po ri C/] N "O O d G rt O O 3 L d :3 X (D 11 . CL -n E N N CD .7. N CD :3 z a fn m n o 0 CL3 N o m m _ O (D (D o @ = (D U) v o 0 < m ° a CD ° 0 ~ p N A cn O O S (n O A 7 O N N O ~ N O (D Q a r n m A 0 :3 A A CD ~p O I A N rn O a O (D o b O O y 0 i ti ~1 Parcel 030-2066-70-000 01/23/2006 04:36 PM PAGE 1 OF 2 Alt. Parcel 35.30.20.609B 030 - TOWN OF SAINT JOSEPH 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 - NORELL, JOSEPH M & JOANNE M JOSEPH M & JOANNE M NORELL 195 RIVERVIEW ACRES RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 195 RIVERVIEW ACRS RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.810 Plat: N/A-NOT AVAILABLE SEC 35 T30N R20W PT GL 4 COM SE COR SEC Block/Condo Bldg: 35, N 817.88 FT, S 85DEG W 213.54 FT, WILY 99.38 FT TO POB: WLY 99.38 FT, S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 11 DEG E 298.64 FT, S 23DEG W 351.5 FT N 35-30N-20W 88DEG E 50.3 FT N 47DEG E 188 FT, N 40DEG E 148 FT, N 17DEG W 263.2 FT, N more... Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 726/497 07/23/1997 701/439 2005 SUMMARY Bill M Fair Market Value: Assessed with: 84663 338,500 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.810 101,400 206,500 307,900 NO Totals for 2005: General Property 1.810 101,400 206,500 307,900 Woodland 0.000 0 0 Totals for 2004: General Property 1.810 101,400 206,500 307,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 115 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T N-R W ADDRESS O~ G1~ V;,-~ Cr~_. ST. CROIX COUNTY, WISCONSIN o. SUBDIVISION A(Vf<cyTt r LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH;R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I r~ Po -A' 'Mow-o LO / ~ OlS'SrrcViPrson/ T F- 4L1Sq(-zPzz061 13F-Q /OZPZ=74, 6; L4f,(Z VA T l~SPx i / /t2vro ~ y3 D,Z~ VL G/~~tACt L'AS T ll2cF2T`/ ~ JYA/3 0~„ GnAt~±- L ~ cv~ -~i yVL jT VVE~L nCSSozn/C C- i I JDICATE NORTH ARRO1i LIVFn 30 'To SCAL,- So~i~IJ ~'ltn~rt7Y Lr.N- BENCHMARK: Describe the vertical reference point used Tp p} j- „ ~Co Elevation of vertical reference point: /Z~ ~ Proposed slope at site: c • n SEPTIC TANK: Manufacturer: f P-1s Liquid Capacity: '/D(U U 'z"' Number of rings used: o'er Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side,O Rear, feet .From nearest property line Front,OSide,®Rear,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: Ii✓ZC: J Liquid Capacity: /SO ZZ Pump/Siphon Manufacturer: I~:;~7r; Nis Pump Size Al 11 Pump Model:J1- _ Elevation of inlet: Bottom of tank elevation: / Pump off switch elevation: 90. C~ Gallons per cycle: . Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. . Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width O Length:_~ Number of Lines: 6 Area Built: Fill depth to top of pipe: / Number of feet from nearest property line: Front, O Side, 0 Rear, 0Irt.~ Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: 4Zn_ Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR iAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ❑CONVENTIONAL INALTERNATIVE sfalePl.,~ID-N~: re, IIf assyne~;l ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 8502934 NAME OF PERMIT HOLDER ~ADDRESS OF PERMIT HOLDER- _N e Joseph Norrel t R. R. , Hudson, WI 54016 BENCH MARK IPer -1, Sete,- -point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV I SE SE, Section 35, T29N-R20W, Town of St. Joseph,Lot#12,Riverview Acr S Name of Plumber. :MP!~MPR$W No Coumy. 5 --y Permit Number 1 Gary Zappa 3300 St. Croix 69599 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV fARNING LABEL LOCKING COVER _ ROVIDED. PROVIDED. DYES LINO DYES LINO BEDDING. VENT DIA.. VENT MATL.. fLGAHRM WATER OADPROPERTY ELLBUILDINGVENT TO FRESH FEET FROM uNE, AIR INLET DYES LINO DYES LINO NEAREST J 2' J DOSING CHAMBER: MANUFACTURER BEDDING. J LIQUID CAPACI1Y PUMP MODEL 1PUMPISIPHON MANUFACTURER. WARNING LABEL JLOCKING COVER PROVIDED. PROVIDED D YES ❑NO DYES LINO EYES LINO GALLONS PER CYCLE: PUMP ANO CONTROLS OPERATIONAL. NUMBER OF PROPERTY JWELL JBUILDING I(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES LINO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nf,rH DIAMETER MATERIAL AND MARKING, or excavation. (If soil can be rolled into a wile, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH IYIDTH LENGTH N BENCHES DISTR PIPE SPACING COVER INSIDE DIA tt P17S LIQUID TENCHES MATERIAL DEPTH: DIMENSIONS P.T GRAVEL DEPTII FILL DEPTH jDiSTR PIPE DISTRPIPE DISTR. PIPE MATERIALNODISTR NUMBER OF PROPERTY WELLBUILDING VENT TO FRESH BELOW PPES ABOVE COVER EFV. INLET ELEV. END PIPES I FEET FROM LINE. AIR INLET: NEAREST--o-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 MEASURED. DYES NO SOIL COVER TEXTURE JPERMANENT MARKERS OBSERVATION WELLS DYES LINO DYES LINO DEPTH OVER TRENCH: BED DEPTH OVER TRENCH BFI) DEPTH OF TOPSOIL SODDED ISEEDED MULCHED CENTER EDGES EYES LINO DYES ENO DYES LINO 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. NO. DISTR. D PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVELEVDIAELEVPIPESDA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED I PLANS DYES LINO EYES LINO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING: FEET FROM LINE ❑ YES El NO YES ENO NEAREST Sketch System on Retain in county file for audit. Reverse Side. T ITLEDILHR SBD 6710 (R. 01/82) rGNATURE Mmmm~ wisconsin APPLICATION FOR SANITARY PERMIT ~ DILH 53711 ~r nwmmwm~ oERRRrmEnr of (PLB 67) COUNTY - In0USTRV,LR60R&"UMRnRELRTIonS UNIFORM SANITARY PERMIT # f/11?5`9C/ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8YZx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER NaR~-~~ MAILING ADDRESS PR ERTY LOCATION Uo l)D~~` LV/S G CITY: VILLAGE: 1 /4 SE1/4, s 35, T 2'/N, R -2-9 E (or) W TOWN OF: ff---- LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ~Z NEAREST ROAD, RK STATE PLAN I.D. NUMBER AKE OR TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedro;tms: 13 ❑ Public (Specify): THIS PERMIT IS :RA A New System ❑ Tank Replacement ❑ Replacemenbsorption System Repair Alternate SyEl Revision ❑ Privy L~ Reconnection El Petition for Modification F THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ See ❑ Seepage Trench l ❑ System-In-Fill ❑ Seepage Pit ❑ Holding Ta ❑ In-Ground Pressure ❑ Vault Privy ❑ Ivy ❑ Existing, For Which A Previous Permit Is an F' El An Existing System That Has Been Inspected And Is Compliant As ssued onditions. Total of Prefab. Septic Tank Capacity Tanks Concrete Constructed Steel Fiberglass Plastic Lift Pump Tank/Siphon Cham Holding Tank cap Ma urer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity /dzTr> Lift Pump/Siphon Chamber 7v_ x Manufacturer: 60 / c-,, reel? E o Ge~5_ ~ . PERCOLATION RATE ABSORPTION AREA ABSORPTION AEA (Minutes per inch): REQUIRED (Square Feet): PROPOSED ( quarreF et): WATER SUPPLY: owvSrL- Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): G~ ~A, A P Signatur iNFP r /MPRSW No.: Phone Numb Plumber's Address: 33 00 (7/f) 3~ NW , 35 Al Q Ad~- d YSOfJ W IS Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: J Fee: Date: • ~ ~ ❑ Disapproved , j" (1--, //-7_/. Approved ❑ Owner Given Initial Reason for Disapproval: Adverse Determination i Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. obtai Private mit sewage must OWER IHave a Changes in your uilin plans or yourseptic tank wheneverinecessary us ally very 2 to 3 years. If you have qu st o s concern ng must properly maintained. DILHR, State of Wisconsin. your system, contact your local code administrator or the Bureau of Plumbing, STATE OF WISCONSIN DILHR DIVISION O SAFETY & ~Jr DILHR PRIVATE SEWAGE SYSTEMS BUREAU OFFPLUMBING BUILDINGS 201 E. Washington Avenue, m 141 PLAN APPROVAL APPLICATION P.O. Box 7969, Madison, WI 53707 608-266 -3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration, Document Sales, 202 South Thornton Ave., Madison, Wisconsin 53703, Telephone (608) 266-3358. 1. PROJECT INFORMATION (Type or print clearly) Revision To Plan Number: Narne of Submitting Party (Plans returned to same) Project Name Street & No. or Rural H rJ R e,I IE St P T IC P', Project Location - Street & No. or Legal Description MBING CO. LOT ~L ~~UEQU/,'w -Je Sf %y S~%f/ S~~ 3 S TL? RI. 3 JALIL RD.- HUDSON WIS. 54111 _ _ _ fe, ' City or Village 11108156WWRICHT Zip City ❑ County MS. MASTER PLUMBER LIC. NO 3307 M.P.R.S. Village ❑ OF: MINN. INVALLER & DESIGNER LIC. W0. 00663 Town Telephone No. (Include area code) 3P6 s Ar- his Designer Telephone No. (Include area code) Owners Name Telephone No. (Include area code) _ TOE- E C) P L-L- Street & No. Street & No. fir- s Avp"~ 80'J If City or Village State Zip City or VillaCJe State Zip S-0 -'J 6, 2. APPLICATION FOR: New Mound System (3a) ❑ Groundwater Monitoring (7) ❑ Conventional System - Public Building (1) ❑ Replacement Mound (4a) ❑ Holding Tank (2) ❑ Replacement Pressurized System (4b) ❑ System in Fill (1 ) ❑ Petition For Modification (6) ❑ New Pressurized System (3b) ❑ System in Flood Fringe (1) ❑ Other Alternatives (5) 3. FEE COMPUTATIONS (Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO DILHR 3a. 750 1,500 gallon septic tank x 50.00 4a. 31b. 1,501 2,500 gallon septic tank - 60.00 4b. 3c. 2,501 5,000 gallon septic tank - 80.00 4c. 3d. 5,001 9,000 gallon septic tank - 100.00 4d. 3e. 9,001 - 15,000 gallon septic tank - 150.00 4e. 3f. Over 15,000 gallon septic tank - 250.00 4f. 1 3g. 500- 1,000 gallon dose chamber 30.00 4Jc. 30 3h. 1,001 2,000 gallon dose chamber - 50.00 4h. _ 3i. 2,001 4,000 gallon dose chamber - 70.00 4i. 3j. 4,001 8,000 gallon dose chamber - 90.00 4j. 3k. 8,001 - 12,000 gallon dose chamber - 110.00 4k. 31. Over 12, 000 gallon dose chamber - 150.00 41. 3m. 500 - 5,000 gallon holding tank - 30.00 4m. 3n. 5,001 - 10,000 gallon holding tank - 55.00 4n. 3o. Over 10,000 gallon holding tank - 100.00 4o. 3p. Revisions - 20.00 4p. 3q. Groundwater Monitoring Per Lot - 32.00 4q. (other than a proposed subdivision) Subtotal - 3r. Priority plan review: walk through) 4r. Submittal of plans in person, by appointment, with double fee 3s. Petition for Variance Setback - 25.00 4s. Site evaluation - 50.00 Total Fee Note: Fees pursuant to Wis. Adm. Code, Chapter Ind. 69 may be subject to change annually DILHR-SBD-6748 (R. 03/84) Effective July 1, 1984 -OVER p,[Z,- Ji;CT TI1D~;X S?I'.";_i";T OVI,71R: 'To c a Rt TT, S ~vDABo~ C N~DSo,~ wiS. 5~/O/~ S I m.E : L D T /2_ ~i lJE,P Ple- w ~ S S,~ s~ IX (f- 3 S TL ~tJ ,f'z a PROJ_ C'T D7SCRIPTT0Id. Cp,c~ 7R "TCST ~2et ~t~ 5*C-AYOAu)ALLy SufiUQr?TE1~ STQ/aT4 s AT- .2. 2 33. ~ y sr~ F ~o w e s~r r~ ~~-e = ys o YoJ51 A M o ~,k3 D s y s PAG 1. PLOT PLAN V I S PAG? 2. MOUND CROSS SECTION & SYSTEM PLAN VTEVV) PAGE 3. PIPE, LATERAT: LAYOUT PAG 4. DOSING OR SIPHON CHAMBER CROSS SECTIONS PAGI? 5. PUMP PERFORMAi),CE SPECS OR SIPIjOit SPECS PLU1,1FT R: STTI, sVATjUATT.R or DESIGNEIR G 4Rr s# .3 3 v o 3S` ~UDSD~ HOMESITE SEPTIC PLUMBING CO. R1. 3 O'NEIL RD.; HUDSON; WIS. 54016 / S 4101 ROBERT ULARICHT Z d S MINN, & PLUMBER D SIGN RL IC3040. 0663 DAT ill SIGNTTUR" . PI.tJ~~ ~tivt~ , ~f V Y { A !j 9 3 4 LiDdsTRY, LABOR, AND HUi`!P a FhA~ pE SA` y NQ 'UiLDl dt 'RESPONDENCE SE";_ ~ j V W 3 ~ ~ ~L) ~~'P~~w ,q~s PAP%U~TE" ~t7 • ~ U O 2 O O H ~a N 14 t- o n Wa~~ CZ W ~ q Or S Ilk`V o o O 2 k 41 o x O I1 ~9 42k . o r Oi NDUSTRY f1 OF S f L Page _ Of Straw, Marsh Hay, Or Synthetic Covering \ II Distribution Pipe Medium Sand G Topsoil F E _ D 3 I I II b 2 % Slope Bed Of z~ Force Main Plowed LJ 33ING Aggregate From Pump Layer /.2 Grass Section Of A Mound System Using - eb FNife'd For The Absorption Area F S '_:~r,~-Iv! t Dt 4~ t r v I,:.! BUILDIW,~ G ~ O A Ft. H 1.5 g e C~ GOR:d%sPONDENCE B yf7 Ft. License Number: 1 Ft. ---9 , Date: J Ft. K 116 Ft. Position L _..67 Ft. ) of - Force Main W 2-9 Ft . 0 Observation Pipe I-- B K A -----------------------I I~ Distribution Bed Of 2 2 2 Pipe Aggregate I Observation Pipe Permanent Markers 30~ V 1(~~ /.S4A Plan View Of Mound Using A Bed For The Absorption Area i ' Page Of - 'S ~ { - T , t~'ei fui ulo,l, hI~e U01itII End View End Cop Perforated / a PVC Pipe ~o`~a~o 06 Holes Located On Bottom, S Are Equally Spaced l~ J PVC ~~~48® .~fr k Manifold Pipe o Distribution Pipe Force Main r. Last Hole Should Be Next To End Cap End Cap I:, Distribution Pipe Layout p Z'? +.)~E~~ Ft. S -3.2- 4t t r A : 4 h w+X 30 0 . Inches LA f 10 t i Ft~, LA ~~2 u1L!:,,,,3~ Inches ~ Signed: Hole Diameter Inch 41 License -N SEE CO i~RE Lateral Inch(es) Manifold Z Inches Date: Force Main Inches # of hol es/pi pe Invert Elevation of Laterals 775 Ft. i' r.. ~Z ✓li9~5~ S f~{~9O . ~o ~A?E.Pr¢~ X/Z M -~t) ~ t' PAGE OF PUMP CHAMBER CRO55 SECTIOU AMD SPECIFICATIOUS Gv>' AViNI, ~a S~ -r w5l Af- Y. VEFJT CAP '1"C. I. VEIJT PIPE WEATHER PROOF APPROVED LOCKIMG 25 FROM DOOR, JUUCTIOM BOX MANHOLE COVER pV 40yti~ WIMDOW OR FRESH 12"MIIJ. 1 1 l~~ AIR IMTAKE I 0 GRADE 40 AIM. 41 I Quick v~sco.~,~e~T _ _ v, 16' h11 u. CO►JDUIT I8'MIIJ. ~ - l~ I►JLE T PROVIDE P AIRTIGHT SEAL APPROVED JOINT A!3Af,~(cC I III APPROVED .1C W/C.T. PIPE I III W/C.I. PIPE OIJTO SOLID SOIL a t- I I ( ALARM EXTEWDIAIG B I II ONTO SOLID yy c , _ _ I I o►J d •I I CLEV. FT. ~ T PUMP c ~ OFF p D 1?6-710~1 V COUCRETE BLOCK (//vs~~~~ - RISER EXIT PERM11T"ED OIJLy IF TAIJK MAUUFACTURER HAS SUCH APPROVAL v1 pilplo ~ ~r`ODIN(z SEPTICE 5PCC.IFICATIOKJS DOSE TAKIKS MAUUFACTURER: IJLIMBER OF DOSES: PER DAy TAIJK SIZE: GALLOIJS DOSE VOLUME /.50jut ALARM MAWLIFACTURCR: ~ l/EL fIL~~P~r IMCLUDIMG BACK/LOW: SGT / 'ZaGALLO MODEL ►JUMBER: V. CAPACITIES: A- 2- ys I1JCHfS OR GALL01 SWITCH TJPC: MEA6&yX lrGdlf/ S Q 5= IIJCHES OR 3(~P GALLOI PUMP MAIIUFACTURCR: ZOO/~E/~ L~ 72- fC C = INCHES OR (,ALLOT MODEL HUMBER: Zr!p On INCHES OR / GALL SWITCH TYPE: 1"~Z2f f/o fTf 2) MOTE: PUMP. AMD ALARM ARE TO OC Fr. w/~14- 10•2 MIMIMUM DISCHARGE RATE -72- GPM INSTALLED ON 5EPARATE CIRCUITS VERTICAL DIFFEREIJCE DETWEEAI PUMP OFF ARID D15TRIBUTIOIJ PIPE.. S FEET + M UIMUM METWORK SUPPLY PRESSURE . . . . . 2.5 FELT + /0 FEET OF FORCE MAIM X ___F o pCFRICTIOU FACTOR.. ' y FEET TOTAL Dy JAMIC HEAD = /0. FEET IIJT[RkIAL DIMLWSIOQi of TAWK: CFI ;WIDTH ...=7 r;LIQUID DEPTH SIC, HE D: LICEOSE ►JUMF3ER: DATE: T D H HEAD' CAPACITY CU RV E U W ~S LU 2 30 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING SERIES 53-55-57-59 97 137-139 163 765 28 M LTRS LT RS LTRS it LTRS LTRS 7.52 163 248 394 231 231 EFFLUENT AND DEWATERING 3 os 129 216 300 231 231 26 ` 4.57 72 163 242 227 227 \ SEWAGE AND DEWATERING 6 10 1G4 13s 23 227 ` 7.62 -30 216 223 9.14 206 220 24 ,2,9 _ ,7z z06 os \ 15,24 125 191 \ 22 18.29 - 57 161 €'-~TSijF 21.34 _ 174 70 , 24.38 53 MODEL\ MODEL P UI 41N o~kval e- 19- 245 26 - 66 87 20 65 163 \ 165 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE SEWAGE AND DEWATERING \ \ !f'j SERIES - 267 268 282 284 793 18 \ \ M GA LTRS :CiAt LTRS GA_ LTRS LTFS GAL .rHS 1.52 408 386 r 492 6F. i ' - P~ 3,p5 .227, .273 360 5y:-. 11 \ i r` ~ r 16 \ c l:e LT '_457 0 .:7s 163--. 238 51 _ 50. 6.1 0 - --30 - + 125 7.62 14 45` ` SEE CO E IS) ON : 4 - 5, r7 \ , 3 10.67 60 12.19 - - 46d \ 13.72 - - 12 40 26 0 \ 15.24 \ MODEL Lock Valve: 18 ' z r- - t 6 35 10 -35 293 30 ` MODELS 8 \ I 25 _ 137 139 6 20 I MODEL ,15 - 284 4 MODEL MODEL 10-- 268 - 282 2 MODELS v 53, 55, 5 57, 59 MODELI -MODEL Q 97 _267 _ GALS.. 10 20 - 30.:40 50 60 70 80 90 100 1110, 120 31 140 1150 160 170w 18 LITERS 80 160 240 320 400 480 560 640 650 FLOW PER MINUTE 3280 Old Millers Lane Manufacturers of O P.O. Box 16347 Louisville, Kentucky 40216 (502) 778-2731 QUA[/7-Y ~uMPS ~YCE ~,9~j7 8 v ~ y ~ m CO) 00 -I W fA to v O N W~ C C r Q3 0 lWD O D < p CD a O X, n n CD O r =r ID p Z ' S. =r _O 3 j (Q (O "p j IA ID O p =r (D ~ CD CD p A Dy O j (D (n CD O N C 1 ' 0 CD * M O CD w w =r CD M =r C-0 n 0 CD CD 00 ,0 CD co w S ? j 0 0 C 3 ° C l< O 3 O a 0 Z c c `G O O C C w C (n (D w w N O Al O O p a CD O w co M C 'a n < CD N 0-. cc (pn p n ° D W Q n C C = a = w cc '"I ° O O a w o . aQ= w O ~m 0NCD v~~w (n C N :3 (A Ll ~ (1 ) * :E Ei Z D 0) cn :3 0 CD CD -0 ice ~ _Z aCD ° 3 CD m ?OL n -1 C CD =r o 0 =r w CD o ~ Cr CD O w OL =r CL (C) CD o FA, (n w w S. C m v (D _=r m c o a - (D : m CD (n CD % (n (n 0 O pad ~vcw O ti p (a a CD 0 0) w ao~ a (cnCCawo' R1 w' w aaaCD (n ° a0 C1D a::rN. c G) . 5-~ < CC w Er CD (n O o G) (O C t- Cp N 3 ~ y n CD 0 C 7 0 N O c wa O a C w (~D CD C CD m Q A O c a C a1 .z o 0 -3 wa a°w p ~r cn co a CD 3 O Z • w 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 C C " 4 Location of Property Section , T N- R W Township FP Mailing Address /<OL)1 AI 'D S Jvd G.~ s S hj Subdivision Name J~FI~'2~~ . Lot Number Previous Owner of Property C;At,, Total Size of Parcel ~2,P Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes V 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 •r. 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) eenti6y that att 6tatement6 on .th.ia boom ahe .tAue to the but o6 my (ouA) knowledge; that I (we) am (ahe) the owneh. (a) o6 the phopeAty des cAi.bed in .th.i.a .in6ohmation 6onm, by vi tue o6 a waAAanty deed teco4ded in the 066.iee o6 the County Reg.iA teh o j Deeds as Document No. T031 6j ; and that I (we) pneaentty own the pn.opoaed 4ite bon the sewage ciapoea zya.tem (oa I (we) have obtained an eaeemen t, to Aun with the above des en ibed pnopeh ty, bon the conattAuation o6 said a y.6 tem, and the name has been duty 4eco4ded in the 066.ice o6 the County Reg.ia.ten. o6 Deeds, ab Document No. VO j6-., ) .4 7 ~ J SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 7--(-kr DATE SIGNED DATE SIGNED ' H r-H 9 r STC - 105 r 9 ti SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d 9 H OWNER/BUYER N-'56P14 Al, No' JUG Z-- - ROUTE/BOX NUMBER Fire Number CITY/STATE Cf~'~~>1 I (,2JZ5. ZIP 5`l0l 1 L~ ~ I PROPERTY LOCATION: :it', Section T N, R 20w, I St. Croix County, Town of S i _ ~r, ScpN- Subdivision Lot number 1 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 H three year expiration. o E r I/WE, the undersigned, have read the above requirements and agree U, to maintain the private sewage disposal system in accordance with H 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 St. Croix County Zoning Office P.O. Box 96- 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) MAD P.O.ISON, WI BOX 53707 HUMAN RELATIONS \ / 7969 3707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP LOT NO.: BLK. NO.: SUBDIVISION NAME: sE 3S /T2 N/R 10E (o s,<. ~'o s~;I+~~Pa,~~:~ ,P.v U~w s COUNTY: OWNER'SS NAME: MAILING ADDRESS: 51'GW X 1) ®,J IVoRRC 1~fo L,~U~%v 6A't_ Q USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTION : PERCOLATION TESTS: Residence 3 ❑ Replace ©C 31' d y~ r. New 0 ^ O RATING: S= Site suitable for system U= Site unsuitable fom /7~/ CONVENTIONAL: MOUND: IN-GROUND PRESSUN-FILL HOLDIN G TANK: RECOMMENDED SYSTEM:(optional) D s ou 2_ cis ®u ©u o s ©u del Z2 If Percolation Tests are NOT required DESIGN RATE: [Floodplain, an under s.H63.09(5)(b), indicate: Y portion of the tested area is in the indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i B- / 7o' 7y q j Ad- 33 ' yam' 'P/'-ems, a,3 - 33 o nix B- 3,yZ' Of. Cs w/ H01~~Ep S/ r° c~~T-r BAY 6S -Au. B-2 ~o fir- 3 0 ~.o' ~y. C/ s;4 OR-6y. w .ca-F Oe JW . Si AA.) -6 Y. S-il, L67 61/. B-3 6.5 l S ~ y ~ 30 Si w f f 0,11! - j 140fS 1.0' 13A,00 o f -F,;, '-D. Q'3. S/ B- •S' t4_4 sy. S1 31 P-4- w, f.f II40Is . p, 'V • s,/ 6 6.0 Qa ' b,~. sil w/ ~'c. aR-G y. Hofs~ . S - v Y. Cf w idt _4 6-. PRO A-4 PERCOLATION TESTS s~ TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ t Z 36 2 P- P- Z Z ,p / L P- 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. ,p4aS-t_ S,4, VC) 7,uf4 7• r2 -C FT . SYSTEM ELEVATION ox~ - %N y&i2r OFT ~7 5 Fr, 1104 IWAJ 13 AMT /'Y 1-5- 7 -0/ 0 9 1vER VA '5,4` P3 P Y cvl D~oaF lf~- L 3 a~ C%149-TloA) = f Od p rr. ; ' TN E 80 /3y is 40CO(A 'Lof - of Poe. l 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): MUMLSI SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 3 ADDRESS:S, MASTER PLROBERT ULBRIGH, UMBER LIC. NO. 3307 W.P.R.S. CERTIFICATION NUMBER: PHON NUMBER(o tional): MINN. INSTALLER &DESIGN ~0)- yP Z 7/,S CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - ks ~)l00 t OH cip t "t3 ilF °u4 A X l AM l'i"Itt u 7z Ci"be(i`c€ It .k E..,a 11331 *.F x:#::3i t~; k, this n~evv or E :-t SITE a?vl~TAB 3.. : i.., ~ S'';"}k '3 31.) Y_ 4,,,0 E`4'g31 1 €L~;~`(?-tr PL U SE usc, Me MA P A LEGIRLE 3t:i,vr1~ a{c {r, d% law, p -ur te.,t lec -n v st=l atFlit' S#kt,.` `F'l r t Cl ti(1" F L''t ee ,.,.t y > . and i> 9 a.1€,~al cl - Sion are yak 3riv shown, a-A aFe pet aan ` C a,; #e _ ipp o r tea„ b jam ,s .#5 to dales. lia,rt es, acjldv ..,c-.,, pl' ) maul, pi,lcol."ion to-J t, Lk,.> i,,.i, 1s 'Iuccl l0 ainl v.,ea.7?4, t`tl _vq3 .,s`~€ t~ ` , In 1l-,c, d ,rwo )tian-, G,i E ~a r W,_ u"ji e3,", :ld~ as "i:10 Sands~ - Glavel tJ r.a, fir`' S Lirnw ~ , re ll. „t,; i. afI 'tai B S HI V t~ - 'rrt?t'.; tr S 1. , _ C3'." , a_s , ?i[;,~a. a + ~ }st t ,3:31 1,17 t°€ e ± t,. ~..lt litr ? PLAN APPROVAL Safety and Buildings Division b i L H Bureau of Plumbing P.O Box 7969 ❑ General Plumbing Plans Madison, WI 53707 ❑ Private Sewage Plans Telephone: (608)266-3815 OFFICE USE ONLY Plan Identification No. 1/5 r { lOy j~V Gallons Per Day r_ t eF t PRIORITY PLAN REVIEW ONLY Plan Review Petition For Modification Project Name Project Location - Street No. or Legal Description ounty F-1 City El Village El Town of: The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan approval must be obtained. ❑ FOR PRIVATE SEWAGE PLANS: This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. Comments: By: James Sargent Bureau Director If Questions Plans Approved By: Date Approved: Contact cc: ❑ OWS ❑ DPS ❑ H&R & Rec. San. Section ❑ County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other 7" T ST. CROI X COUNTY t WI SC0 N S I N ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 June 5, 1985 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Joseph Norrel property located at the SE4 of the SE34 of Section 35, T29N-R20W,Lot #12, Riverview Acres, Town of St. Joseph, St. Croix County, revealed suitable soils at a depth of 2.8 feet, 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. Si erely, 0 40MU' a- Thomas C. Nelson Assistant Zoning Administrator TCN:mj STATE OF WISCONSIN-bMAtft vT OF INDUSTV , 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: TownshipJffdbWXy1K SE !4 SE 141S 35 T 29 N/R 20 )O W St. Joseph St. Croix Street Address: Subdivision: County: Riverview Acres, Lot#12 Landowners Name: Mailing Address: Joseph Norrel 5 Audubon Ct., Hudson, WI 54016 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. Signature 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 SE 1/4, SE 1/4, Sec. 35 T 29 N, R 20 W Town XXXJkmAxA;m ty St. Joseph Street Address Lot No. 12 Block Subdivision Riverview Acres Landowner's Name: Joseph Norrel 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: (.1 to have one of the first five approvals guaranteed for this year. This is number - - of those applications. quota num ers issued-to~you.) (Use one of the first five one of the applications needing a uota number. The quota number assigned to this application is 59 _ 09 _ for one additional homesite on a farm to be occupied by a grandchild, sibling, niece, nephew, or first cousin. y parent, child, FI for an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. (...]for an application on file prior to February 1, 1980. Ufor 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: ❑ a 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 .El I certify that the above information is true and accurate to the best of my knowledge. Name Thomas C. Nelson County Official 5~9+`~ ure Title Assistant Zoning Administrator Date June 5, 1985 DILHR-SBD-6158 (R 12182)