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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ;(SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 Cfc X R L~ 4 D(' BUREAU OF PLUMBING
MADISON, WI 53707 l
❑CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
PRIVY (If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Bob Ahrens R. R. 3, Box 74A, Hudson, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PL ELEV.
SW SW, Section 18, T28N-R19W, Town of Troy
Na- of Plumber. MP/MPRSW No. C-my. Sanitary Permit Number:
Bob Ahrens N/A St. Croix 64890
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAP ACITV. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
DYES ENO DYES ENO
BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: JPROPERTY WELL: BUILDING: IV ENT TO FRESH
ALARM FEET FROM LINE. AIR INLET.
DYES ENO DYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODE I. IPIJMP,SIIHON MANUFACTUREH WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ENO EYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPEHTV JWELL. BUILDING. I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) EYES ENO NEAREST-3.
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LDIAMFTEH MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH'. LENGTH NO. OF DISTR. PIPE SPACING. COVER JINSIDE DIA. stp1T5 LIQUID
BED/TRENCH TRENCHES MATERIAL: PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER C PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOVE cOVER ELEV IN LL f ELEV. END PIPES'. FEET FROM LINE. AIR INLET.
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-
D meets the criteria for medium sand. TIONS MEASURED.
YES ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ENO DYES ENO
DEPTH OVER TRENCH; BED DEPTH OVER TRENCH ;'BED UEPTH IF TOPSOIL PI.D SEE DEDMULCHEENTER EDGESS ENO DYES ENO DYES ENO
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 Mzj NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. CIA. ELEV. PIPES CIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY ERIAL VER TICAL LIFT L'ORRESPON OS TO APPROVED
PLANS
DYES NO DYES ENO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE
DYES ENO DYES ENO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
DILHR SBD 6710 (R. 01/82)
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nsin APPLICATION FOR SANITARY PERMIT eltz~
I L H R (PLB 67) COUNTY
IEnTOF UNIFORM SANITARY PERMIT #
z:: TR V, IfiBOR 6HUmfin RELfiTlOnS /f] -
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 iinf}c`hes in size..
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
AHRENS ROB'T. S. RT. #3 - BOX #74A SDI'
PROPERTY LOCATION CITY:
SW 1/4 SW 1/4, S 18 , T2 8 N, R 19 (or) W T LAGfOWN TROY TOWNSHIP
LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK r ATE PLAN I.D. NUMBER
ST. CROIX RAILROA SOUTH COVE RD.
TYPE OF BUILDING OR USE SERVED p~C I Q
A
El 1 or 2 Family Number of Bedrooms. Public (Specify): 1, ~Aec,
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision X 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
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity 1000 1000
Manufacturer: MIDWESTERN PRECAST INC. MENOMONIE, WI.
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: NONE
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Pq YV ❑ Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installati of prva sew sy tem shown on the attached plans.
i
Name of Plumber (Print): Signature: MP/MPRSW No.: Phone Number:
AHlZENS, ROB'T. S. l ^J 715 ) 386-3311
Plumber's Address: Name of Designer:
RT. #3 BOX 474A HUDSON, WI. 54016 SHE SAME
COUNTY/ DEPARTMENT USE ONLY
Signatu e of Issuing Agent: Fee: Date:
Disapproved
Fyn /'~011f r~~ ❑ Owner Given Initial
~'~~/'t'S Approved Adverse Determination
eason 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.
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ST. CROIX RAILROAD
931 Brenner Ave.
5T. PAUL, MINN. 55113
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ST. CROIX RAILROAD
931 Brenner Ave.
ST. PAUL, MINN. 55113
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