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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 O - BEHLING, GORDON R GORDON R BEHLING C - %WEIGH-RITE SCALE CO %WEIGH-RITE SCALE CO PO BOX 396 SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 425 CTY RD V V SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 3.590 Plat: N/A-NOT AVAILABLE SEC 5 T30N R19W N1/2 SW1/4 LOT 1 C.S.M. Block/Condo Bldg: 6/1589 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 05-30N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1109/445 TI 07/23/1997 832/332 07/23/1997 724/308 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 3.590 65,800 33,400 99,200 NO Totals for 2006: General Property 3.590 65,800 33,400 99,200 Woodland 0.000 0 Totals for 2005: General Property 3.590 65,800 33,400 99,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges 00 Total 0.00 0.00 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT T N-RW OWNER TOWNSHIP SEC. ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE 1. t PLAN VIEW Distances and dimensions to meet requirements of I1,HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ICI y~ J J R ~J INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used f>1=- Elevation of vertical reference point: l~:'iJ Proposed slope at site:%"%'c SEPTIC TANK: Manufacturer: ~_~j ~ Liquid Capacity: 7 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation:-/O/ Tank Outlet Elevation: Number of feet from nearest Road.: Front ,~Side 10 Rear, O feet From nearest property line Front, GSide,0 Rear, O lei /7 feet Number of feet from: well building: L (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pum Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch ele tion: Gallons per cycle: Alarm Manufact er: Alarm Switch Type: Number of eet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM- Bed: Trench:- Width: Length: Number of Lines: - Area Built: =r~) Fill depth to top of pipe: t Number of feet from nearest property line: Front, ` Side, O Rear,0 Ft: Number of feet from well: r _ Number of feet from building: j' (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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: ' ( 7 car Dated: Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 CXkONVENTIONAL ❑ ALTERNATIVE [111, P111,1 1, r per COMMERCIAL ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 8~~1~~ 178 NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER INSPECTION DATE Ken vtr.enl L ynne Foss e 1007 Lincotn Lave, Huct5 on, WI I ~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.'. CST REF. PT. ELEV NW SW, Section 5, T30N-R 19W, Town o4 Some&6 eat N~mr of Plum her MP/MPHSW N,, Garay L. Slteet 3254 S Cnoix 74991 SEPTIC TANK/HOLDING TANK: MANUFACTURER LI QU ID CAPACj=Y TANK INLET ELEV TANK OUTLET ELEV WARNING LABEL LOCKING COVER ( I, PROVIDED PROM FD YES LINO F- N0 BEDDING. VENTDIA.. VENT MAT( HI( ;H WATFH NUMBER OF ROAD. PROPERTY JELL . - BUILDING VENT TO FRESH / nLAHM FEET FROM / LINE j i AIR INLET OYES NO- C I DNO _ NEAREST- ~~~i I_ j DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MOUE( PUP SHON r'AtiUl n(.I UHLH WARNING LABEL LOCKING COVER IP PROV PROVIDED. OYES LINO YES LINO OYES LINO GALLONS PER CYCLE: PUMP AND C ONT ROLS OPER AT ION A L NUM R I)PFHTY WELL BUILDING VENT TO FRESH NF AIR INLET (DIFFERENCE BETWEEN FE F Py PUMP ON AND OFF) OYES _1N0 N AR SOIL ABS ORPTION SYSTEM. Check thesoil moistureat thedepth of plowing F TH cTAIFHAI AND MAHKIS(, 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: WIDTH LENGTH NO OF DISTH PIPI Sf A N:. )VI R III,. ' Ir. ~ BED/TRENCH /TRFNCT I r ,f j I-( ~~_pI T LDIEQPUTID H DIMENSIONS 1 oil l 7 PIT GRAVEL f)FPTH FILL DEPTH DISTfF PIPE DISTH PIPE DISTR. PIPE MATRIAL NU/1 T It NUMBER OF PHOPE RTY WELL BUILDING VENT TO FRESH BELOW PIPFS All OVER FI E V wn T E [V END( PP ) L NE AIR INLET ,.J ~I : / ) I„L, FEET FROM NEAREST _ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES NO SOIL COVER TExTDRE PE IINIANINT^.'-AHKFHs UWAHVATIONWFLLS OYES _ LINO O YES LINO DEPTH OVER IRFNCH PFD DEPTH OVFH THENC'H BF O Uf PTH ()f i(lPS!III of IIIDf D JSF E NF) MULCHED CENTER EDGES LiYES. C~NO OYES LINO DYES LINO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF L ATEHAL SPACING GRAVEL DEPTH HF LOW PI PI FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES I DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE IMANTFOLDMATFRIAL NO UISTH UISTH PIPE: DISTHIBLITION PIPE MATERIAL&MARKING ELFV ELEV DIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOT ESIZE ROLE SPACING CHI FILE D COHHE C T LV COVFH MATEHIAI. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS _ OYES NO OYES LINO COMMENTS: PERMANENT MARKERS : OBSERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING. FEET FROM LINE DYES []NO 'YES INO NEAREST- Sketch System on R ain in county file for audit Reverse Side. _ SIGNA TU- TITLE' DILHR SBD 6710 (R. 01/82) E 11111111 Wisconsin APPLICATION FOR SANITARY PERMIT `may Z, &OZX COUNTY DILHR oERRRTmenT OF (PLB 67) UNIFORM SANITARY PERMIT # InOUSTRV, LRBOR 6 HUMRn RELRTIOnS 7 X!2Z -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER 11 MAILING ADD SS SS ©G` PRO ERTY LOCATI N fJ k3 /4 j,11/4, S T3C) N, R /c' fi,,(or) W TOWN f LOT NUMBER BLOCK NUMBER JSUBDIVISkON NAME NEARESTp AD LAKE OR LANDMARK STATE PLAN I.D. NUMBER A~ 26 TYPE OF BUILDING OR USE SERVED ii ❑ 1 or 2 Family Number of Bedrooms. Public (Specify): < I ~S THIS PERMIT IS FOR A: KNew System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill In-Ground Pressure ❑ Vault Privy ❑ Pit Privy Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed y. Septic Tank Capacity A5 ti n Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed 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): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. r Name f Plumber (Print): Signature: /MPRSW No.: Phone Number: /Ste - ' Z J ( ?ls) Z C-(o Zoe Plumber's Ad ess: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature o Issuing Agent: Fpp: Date: Disapprove I L~ Owner Given Initial ~ Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 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. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 7= /may J tz7a~ fi i~ - Doc 4---4z Spa e _ r. No - ~ ~ RECEIVE) SE:) 1 C, 190r ~a ~ ° I f VJ I r 11 r 1 Y' C P9~ s ('T_y A VVV per'. `'Y/ y C-V I ~ i L-4-11 i , RECEIVED I s p 1 z~ I ~c K PAGE OF i oat" 1 ~ ~ -tvgVic_h CRC S SE TIOK " OF A 4WO SYSTEM SOIL FILL DISTRIBUTIOAI PIPE APPROVED 5yNTHETIC COVER 2" OF AGGREGATE 2jq Z`o ~-'MATgRIAL OR 9" OF STRAW ~,`,/e R MARSH HAS ~3 le~OF% -2,/E, AGGREGATE ELEV. OF~ FEET_~ DISTRIBUTION PIPE TO BE AT LEAST INCHES BELOW ORIGINAL GRADE ARID AT LEASTLO INCHES BUT NO MORE TRAM 42 IAICHES BELOW FIMAL GRADE MAXIMUM DEPTH OF EXCAVATION FROM ORIGINAL GRADE WILL BE INCHES MINIMUM DEPTH OF EXCAVATION FROM ORIGIUAL GRADE WILL BE INCHES 8 SIGNED: RECEIVED LICENSE NUMBER: ,r Cy' v~ 1 DATE : / 8 ' 'Z~ DILHR PLAN APPROVAL Safety an Buildings Division Bureau o P um ing P.O Box 969 ❑ General Plumbing Plans Madison, WI 53707 ` Private Sewage Plans Telephone: (608)266-3815 Plan Id rntification No. c7 Gallon Per Day PRIORITY PLAN REVIEW ONLY Plan Review Fee Received Petition For Variance Fee Rec. Project Name Project Location - Street No. or Legal Description unty ❑ City ❑ Village `Town of:C-5 G V _ 11 I X, 1 he plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval iti 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: 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 PLAN (1) (2) (3a) (3b) (4a) (4b) (6) (7) This approval will expire two years fro the date approved below 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 Plans Approved By: Date Ap roved: Contact cc: rivatJSe age Consultant ❑ Plumbing Consultant ❑ Environmental Health County ❑ Local PI ❑ Facilities Need Analysis Section I UW-SSWMP ❑ Plumber ❑ Department of Agriculture Dii HR-SBD-6099 (R. 01 85) Owner ❑ Other STATE OF WISCONSIN DILHH DIVISION OF SAFETY & BUILDINGS 133 L H R PRIVATE SEWAGE SYSTEMS BURE OF PLUMBING Wash ngt n Avenue, Rm 141 P.O. Box 7969, Madison, WI 53707 PLAN APPROVAL APPLICATION 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 bark 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: $ Name of Su mitting Party (Plans returned to same) Project Name 1 Street & No. or Rur I Route Project Location - Street & No. or Legal Description /y City or Village State Zip City 13 County P " Village ❑ OF: Town ❑ i m 7 l~ t/ Telephone No. (nclude area code) J '7 14, Telephone No. (Include area code) Designer Telephone No. (Include area code) Owners Name`/` 1 C Y { _ J ` Street & No. Street & No. ' - G City or Village State Zip City or Village State Zip ❑ New Mound System (3a) ❑ Groundwater Monitoring (7) 2. APPLICATION FOR: Conventional System - Public Building (1) ❑ Replacement Mound (4a) ED Holding Tank (2) ❑ System in Fill (1) El Petition For Modification (6) El Replacement Pressurized System (4b) F-1 New Pressurized System (3b) ❑ System in Flood Fringe (1) E:1 Other Alternatives (5) 4. FEE SUBMITTED FOR OFFICE USE 3. FEE COMPUTATIONS (Include existing tanks) MAKE ALL CHECKS PAYABLE TO DILHR ~~Y? 3a. 750- 1,500 gallon septic tank - 50.00 4a. 3b. 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. 3g. 500- 1,000 gallon dose chamber - 30.00 4g• 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, PE CE IV ED by appointment, with double fee 3s. Petition for Variance - R 1 I; 1Q^ Setback - 25.00 4s. Site evaluation - 50.00 O® Total Fee P,+f RE Note: Fees pursuant to Wis. Adm. Code, Chapter Ind. 69 nay be subject to change annually -OVER DILHR-SBD-6748 (R. 03/84) Effective July 1, 1984 C..L' DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDIN INDUSTRY, G DIVISI LABOR AN P.O. BOX 7 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 537 (H63.090) & Chapter 145.045) LOCA I IV: c TON: ,r TOWNSHIP/MHWI~IRA.LITY: OT N ILK. NO.: SUBDIVISION NAME: '/r' / / tG (or) W I A)144 42 TY: OWNER AM MAILING ADDRESS: e- USE DATES OB E VATIONS MADE NO. BE- M : ZCR PTIO DESCRIPTIONS: A TESTS 1 -]Residence New ❑ Replace p RATING: S- Site suitable for system U- Site unsuitable for system CONVEN N L: MOUND: IN-G N-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ®S OU DS U S ❑U OS ❑S U I' Percolation Tests are NOT required DESIGN TE: if any portion of the tested area is in the [under s.H63.09(5)Ib), indicate: Floodplain, indicate Floodplain elevation: 10651 PROFILE DESCRIPTIONS 456-'..?6 2 BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPT NUMBER DE,prm. ELEVATION BSERVED EST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B p 3 T ` / A. ``1 7 S.L, 7 A A) wd B- Z aas 0593 p ~s i sv n. //Jo 10 A) '0 17 B- 44 a O(o 6 /VoA-le (OS--8o~aS.,C. B Zs Duo /)On9It- zsS -AleB~.I~~`i3n•~;1. B- ES/n'I/~I PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L V -IN HES RATE MINUTES NUMBER WeHfS AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI PER INCH P- NOr'e- 0 07 0?l~ oil' P- z rs /V C- 0 3y 3 3 Jr P- P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or dista ces. s(rihle'Jrhlt are the h /ontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and perc of land slope. P,0REA J SYSTEM ELEVATION 1, d7 • LEI\hra „~1 Z' PI b. # 60 -1/78 PROJECT DETAIL DATA SHEET f NAME OF BUSINESS LEGAL DESCRIPTION J OWNER in MAILING ADDRESS ~ . c Y S : t Z I P ARCHITECT, ENGINEER, ADDRESS PLUMBER OR DESIGNER l~ r TELEPHONE NUMBER , n LIZ7 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building New building Addition ( ) Apartments and condominiums ' . Number of bedrooms ( ) Assembly hall . . . . . . . . . . Seating capacity ( ) Bar . . . . . . . . . . Seating capacity # of meals served ( ) Bowling alley . . . . . . . . . . . Number of lanes ( ) With bar ( ) Campground and camping resorts . . . Number of sewered 'sites Number of unsewered sites ( ) Total number of sites Camps ( ) Day use only Number of persons ( ) Catchbasin ( ) Day and night Number of persons ( ) Church • • Number __9178 . . ( ) No kitchen Number of perso ( ) Dance hall ( ) With kitchen Number of persons Number of persons ( ) Dining hall . . . . . . . . . . . Number of meals served daily ( ) Dog kennels . . . . . . . . . . . . Number of enclosures ( ) Drive-in restaurant . . Inside seating capacity Car-service Number of car spaces ( ) Dump station . . . . . . . Number of dump stations ( Employees ( total of all shifts) Number of employees ( Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit Number of units with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff Number of office personnel Number of patients ( ) Mobile home parks . . . . . . . . Number of sites ( ) Nursing homes, . . . . . . . . . . . Number of beds ( ) Parks . . . ' ' . . ' . . . . . Number of persons ( ) Toilets ( ) Restaurant . . . . . . . . . . . . . Seating capacity ( ) Showers ( ) Dishwasher and/or disposal? 24-Hour service Retail store . Total number of customers Schools . . . ' . . Number of classrooms ] Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . . . . ' ' . . Number of cars served daily ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER . . , (Specify) . . . . . . . RECElilEG COMPLETE OTHER SIDE F fig 1-1QEAU 2. Indicate whether the following facilities are present. Floor drain yes no Number of drains Food waste grinder yes no X Dishwasher yes no X Automatic clothes washer yes no Number of clothes washers 3. Septic tank capacity /000 !kiA, i Holding tank capacity Septic or holding tank manufacturer 4. SEEPAGE TRENCHES: total square feet width of trenches length of trenches ,4 6 ' depth 04; number of trenches; SEEPAGE BEDS: total square feet width length of bed depth SEEPAGE PITS: total square feet outside diameter depth below inlet total depth from top to bottom of pit Signature o~ person completing form: FOR DEPARTMENTAL USE ONLY lei. z Address f 1 Z i p 4 J 1 9 Telephone Number z c>:' Date 2""-7 f P s y RECEIVED " SEP 1 t OPTIONAL WORKSHEET 1. MOUND SYSTEM. II. IN-GROUND PRESSURE SYSTEM-Continued- 1. Wastewater Load, Total Daily Flow= gal. 10. Force Main: Use s. ILHR 83. 15 (3) (c) Minimum Dosing Rate = spm. Adm. Code and PROVIDE A DETAILED Diameter = in. LIST OF SIZING ON PLANS. i 11. Total Dynamic Head: ' 2. Depth to Limiting Factor ft. System Head = 2.5 ft. 3. Landslope = % Vertical Lift = ft. 4. Distance from Dose Chamber to Friction Loss = ft. Distribution System - ft. TDH = i ft. 5. Elevation Difference Betwssn / 12. Pump Selection: Pump and Distribution System = ft. Pump will discharge at bast gpm 6. Absorption Area Sizing: ; at ft. total dynamic head. Area Required = / sq. ft. Pump model and manufacturer: Bed or Trench Length (B) = ft. Bed or Trench Width (A) = f ft. 13. Dose Volume: Trench Spacing (C) ft. 10 Times Void Volume of 7. Mound Height. Distribution Lines= gal. Fill Depth (D) _ ft. Daily Wastewater Volume 4 Fill Depth Downslope (E~= ft. 4 Doses in 24 hrs. _ gal, Bed or Trench Depth ) = ft. Backflow = gal. Cap and Topsoil Depth (G) - ft. Minimum Dose = gal. Cap and Topsoil D th (H) - ft. 14: Dose Chamber: 8. Mound Length: Volume = gal. End Slope (K) = ft. Total Mound Length (L) = ft. 111. CONVENTIONAL PRIVATE SEWAGE SYSTEM 2 9. Mound Width* / 1. Wastewater Load, Total Daily Flow = gal. Upslopeection Factor= Use s. ILHR 83.15 (3) (c) , Wis. Upslope (I) = ft. Adm. Code and PROVIDE DETAILED Downslodpe Correction Factor = LIST OF SIZING ON PLANS. Downplope Width (1) - ft. 2. Required Septic Tank Capacity = gal. TotarMound Width (W) = ft. 3. Percolation Rate = 2 min./in. 10. Basal rea: 4. Absorption Area Sizing: I iltrative Capacity of Refer to Table 2 in eh. ILHR 83 atural l Soil = gal./sq.ft./day and PROVIDE A DETAILED LIST OF Basal Area Required = sq. ft. SIZING ON PLANS. Basal Area Available sq. ft. Required Area 1 ~ sq. ft. 11. If Standard Tables from Chapter ILHR 83 Length ft. / are used, Indicate Table # width ft. 12. For the Distribution Network, Use Numbers 5-14 in Section If. Number of Trenches = - r? Trench Spacing = ft. 11. IN-GROUND PRESSURE SYSTEM S. Distribution System: 1. Depth to Limiting Factor = ft. Lateral Length = ft. 2. Landslope = % Number of Laterals = 3. Percolation Rate min./in. Lateral Spacing = - • 3a. 4. Proposed System Elevation = - ft. Distance from Sidewali to Pipe = in. 5. Wastewater Load, Total Daily Flow: gal. System Elevation = j ft. Use s. ILHR 83.15 (3) (c) , 4Vis. Adm. Code and PROVIDE A DETA~~D IV. SYSTEM-IN-FILL LIST OF SIZING ON'PLANS. j' Fill in All Items from Section sssIII Mai8 Required Septic Tank Capacity * gal. ° o Q 6. Absorption Area Sizing: V. SEPTIC TANK 5P~I • Percolation Rate = min./in. 1. Capacity gal. Area Required - sq. ft. 2. Manufacturer: j System Length - ft. 3. Show Site Constructed Tank Details on Plan System Width = ! ft. 7. Distribution Pipe S106g: VI. DOSING TANK Hole Sire = In. 1. Capacity = HoleSpacinK= ft. 2. Manufacturer: Lateral Lerixih - ft. 3. Pump MAnulaclurcr: LauvALBiie in. 4. Pump Model: Lateral Spacing It. 5. Operiling Head= It. Uistanu• from Sidaw.dl 10 Pipe in. G. flow Rate= gpm. 8. Ui.ltlbutiun Pipe Discharge Rale: 7. Show Site Constructc ank Details on Plans Number of I lules Per Pipe j I low Per Pipc = gpm. VII. HOLDING TAN 9. Manifold Sizing: 1. Capa gal. type (center or end) - 2. nuliclurer1- Length = It. Show Site Constructed TankeDetails on Plans Diameter = in, -SHOW ALL INFORMATION ON PLANS- s I i(<h'in~^ BUREAU DILHR SOD-6761 (8,03/82) DILHR ~m PLAN APPROVAL Safety and Buildings Division Bureau of Plumbing P.O Box 7969 General Plumbing Plans f Madison, WI 53707 Private Sewage Plans ' ~j nn Telephone: (608)266-3815 Plan Identification No. toc9 r ER S Gallons Per Day PRIORITY PLAN REVIEW ONLY s Plan Review Fee Received Petition For Variance Fee Rec. Project Name Project Location - Street No. or Legal Description { t ; X~i Co/ my i City ❑ Village ❑ 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 anpronn,)L e inspector when inspections can be made. J FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g This approval will expire two years from the date approved below. If construction h I" n(-st cornmen(ed before the expiration data, ne~-v plan approval must be obtained. e F_ FOR PRIVATE SEWAGE PLANS: (1) (2) (3a) (3b) (4a) (4b) (6) (7) 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. 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: i James Sargent Bureau Director I Questions Plans Approved By: Contact Date Ap~roved rc: 7 Private Sewage Consultant ❑ Plumbing Consultant ❑ Environmental Health l County = Cl Local PI Cl Facilities Need Analysis Section UW-SSWMP ❑ Plumber Coln to ~ As;rI( U!i° r V . 1r.-,itu-F,010 t: ;)1 8") Owner Other- SBD 6678 (R. 08/83) (Plb 100a) (Wis Stats. S. 145.02) STATE OF WISCONSIN DILHR Detach And Return Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 141 Any Return Correspondence P.O. BOX 7969 - MADISON, WI 53707 608-266-3815 DATE: RECEIVED PROJECT: OCT 2 1985 1 ZONING - u OFFICE SW, 5,: C-R North Shore Driv, PLAN ID. # DETACH HERE _ - - - - - _ - - - _ PROJECT NAME PLAN ID. # This is to acknowledge receipt of your plans and specifications for the above-indicated project. Preliminary review indicates the required fee is $ 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. 1. Plan Submission ❑ Soil boring and percolation test data on 115 completed ❑ Additional information shall be submitted in duplicate unless by Certified Soil Tester. (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 with Section ILHR 83.08 (2) (a) 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. ❑ Holding tank agreement signed by owner and local 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. 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 to 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. x m x ~ 00 m w c c N 3 a' c 0 fl) z =o SID -0a(DcD2, o? Cn CD - En (n :E u, m 0- 0 ado w o CD m m'cm aw A w -0 CD CD Cn m m v = = 0 ca cn ~ m CCD CD OO o w m 3 a o o m on w w > > o 3oS.3 oa00 zO 0' W:3 1 w ww,~ y~.twu, o m o ~o am 3 m w~01) '0 mcCrn D C c D c m to O n = w o c O CCDL L cD MO Er- .00- m m jam mmwwwcn Z a (Sc ew fj Z N w m m m m a(ND0 3c~Dcn CA D 0 (D (D =r M as ?w -°c w o m Sr U) CD CD o=r CA ac0*m C ft1 cD c= mam C) W CD (o a~ w:3 (=D _ ~ o `c - ,cw co a N 0 O U) 0 C c ~p m y ~j~ r► 1 S m 1 1 N 1 a o~ N c C E- in w o m wow m-~CDCO CL $CD aa~ aE; Q 7 Q N~c (°~wm3 r n I. 0 C ~ co a o cD O M g ao oM c BCD c m ,pm a cow -.~sw~m \I,V a = c m p 0~ 003 a a (D M O 3 3C' ' 3' a o < (D CD 0 1 `"Z o W6 7Z os_5 S~ if s 8506 1 7 8 o~ . lrt~, 3z 5"~ RECEIVED BUREAU DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS N INDUSTRY, LABOR AND P.O. BOX 7969 PERCOLATION TESTS ( / 115l DIVISION HUMAN RELATIONS (H63.090) & Chapter 145.045) ` MADISON, WI 53707 LOCATION: SECTION: TOWNSHIP/ q ITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: 77 p COU~vTY: OWNER' /BUYER'S NAME: MAILING ADDRESS: r c USE NO. BEDRMS.: M Cl L E CRIPTION: DATES OBSERVATIONS MADE ❑Residence PROFILE DESCRIPTIONS: PERCOLATION TESTS: in 1-515 N New ❑Replace Q 7 ~j © Q7 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTION~VL:M UNDI NGROUNSYSTEM-IN-FILL HING TANK: RECOMMEND SYSTEM:(optional) ®S U S ❑U EIS ❑S a2 Q/ If Percolation Tests are NOT required DESIGN ATE: under s.H63.09(5)(b), indicate: If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: PAS/PROFILE DESCRIPTIONS] BORING TOTAL DEPTH TO NUMBER pEp[ GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH 7N , ELEVATION OBSERVED EST. HIGHEST TO_sBy~EDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- - 75 B- aas 1~5tz o z~ 17, .s0 93 00 17 1061 /00 A~IL 04 B- 41 ` PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES NUMBER hPdE+t€S AFTERSWELLING INTERVAL-MIN. RATE MINUTES PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P 7s& a0 / o ~ ~ya ~ P z ~ ,.3 P- 3 7 _ya P_ /i.~ i 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 o b 101(n ih^ t r 14 -1 x 3 _ ~N s PIS E q~ - w T_ e Q i I r _ 6 Q lei I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and me /o lVS gC414 -ffi the ~iissconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. t~;l NAME (print): TESTS WERE COMPLETED ON: 0,9" 9 ADDRESS: yC? - 6) - e 5 CERTIFICATION NUMBER: PHONE NUMBER (optional): zZ57 `JvZ~(-(Zoe CST SIGNA U TRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. SBD-6.3,95 (R. 02132) - OVER i' e SO i a;i.. @€3 ~sr€t3 &:a AI( M l fls ct'~4r ~~t t5 }i t. VL t'i £s' ll sysl-' a 1 ! 4 2 RULED qEr-:- r rate.. _r4 ,t -.€ia.to,1,; `t) 0f 7, c.~.'W iJYti of da ~'rt ti Sc .}.,10)1", ~ E A LE iBLr- dlaara l iccu ; el't locating your ;st kfcatiown . DdVV:.,(j f,., sn ai ra St ':1 i i a £?'_ata C1; r . -e € s - T,r"<i + l.vat o, ;t'oS94,E` rv+)i ,t r3St^ (""1 ,....ir .~:wv 1, and F,w' a .tip a.i'ii € ,t +r= ii E, i f , E cid$i t ` ,3` ttt .i B B f€ - . Sxs :d k""), f CA, x... tt t ;E, ig ° a a, u S,°'t'' - - S ti c . € a~ E ti f t t h(: rt,Y." iu- z Ln H STC - 105 r r a SEPTIC TANK MAINTENANCE AGREEMENT FA St. Croix County ° z v OWNER/ BUYER 172 H /Oss c~ ROUTE/BOX NUMBER ~L Fire Number CITY/STATE PROPERTY LOCATION: 610 14, SQ, k, Section T N, R/ W, Town of ~Ct-7y~ St. Croix County, Subdivision Lot number ,O . 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 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 Office within 30 days of the three year expiration date. ` S I G N E D ,l 7~ I c~,;y 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. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequaoies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property Location of Property i~ Section , T C N _ R _ W Township may,-~ Mailing Address f~ Subdivision Name I . Lot Number A , Previous Owner of Property ~V L/ ~~~AY9~ Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 7 and Page Number L 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) een.ti.6y that att statements on this 6onm ahe t&ue to the best o6 my (oulc) knowt-edge; that 1 (we) am (ane) the owneA (s) o6 the pno pent y da n i.bed in this in6onmation 6o4m, by viAtu.e o6 a wavtanty deed neeonded in the 066ice 06 the County Regiz ten o g Deeds as Document No. ) 3' 7 ; and that I (we) pees en t,-y own the p.upos ed site bon the sewage pas s ys.tem (on I (we) have obtained an easement, to nun with the above dedehibed pnopen.ty, 6on..the const ucti.on o6 said system, and the same had been duty neeonded in the 066ice o6 the County Reg.es.ten o6 Deeds, as Document No. ) SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED _ '