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HomeMy WebLinkAbout042-1077-10-100 o a o a o 3 C) 3 0 O O o°a c. 0. ~ I I N q N L~ I ' O a) Q) c Z = Z co m v LL C U. G O O - - I I (U 3 - - ' (D a) z z " 00 co Z j « O a.% O N O O Z c- I ~ 9 ' ~ O v co (N N I- Z d an d m \ n }4 4-1 ~4 o v 3 3 0 O Z -D U '0 U/ 00 U c c 4-a v o d Z c o o po . c 3 I to F- m ~ Z m (D c E v c E rn 3 'O 0) M Q~7 ?C N O N co N a) H H 00 ~J O c co 0) 1 a 00 CU co a) N y " • ~ ' C ~V ) L N L \ o C O m n O L Ul O Z I- Z O Z co z I Q N z I a III _ d = N _ d = Lr) a c) E m E N t2 is R H a C/] ° o a dam, o CL ~ooa n T c Nona > 3 ~ z~> (n tnv> > o w °v F- cn -4 o 00 z X000 n U z x'000 aU x 00 • ~1 jp 0 a a a y ! d a a cn x H n PQ 3 +j ~4 O a~ .0 Q) LO 0 CO o " x N 0 U C) LO Ln O C~ CO 0) 0) rn z H N m Z: ZZ 4-1 N 00 N Y 0 O _ O >4 a! N a > o o ° E 05 ~ 0 O O > :3 0 N I r- m _pl U ~i 0.i Cq U 9 n N " m N N Q U Q co m o m Q Z U) l0 a-- d lC J 4) L J U) 0p 7 a+ O O N C O N C y O O m O E N O O p a CO Co ) ; w aUi c u d Oo a) m c O 00 F- ami c m 5 (n M c °0 L c m Q) 04 00 v - D o c m 0 `n Y: o 00 • m o O N m o L O N co o O N U CO O Z 2 F- (4 U to O Z _ S Z CC, V v~ Ea ~a EL m d rrw~• a m u m y m a m o N 00 O (D _1 A U V Parcel 042-1077-10-100 01i29i2007 03:43 PAGE 1 OF 1 F 1 Alt. Parcel 28.29.18.4398 042 - TOWN OF WARREN 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 - CODY, THOMAS H & SUZANNE M THOMAS H & SUZANNE M CODY 796 112TH ST ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 796 112TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 6.346 Plat: 1575-CSM 06/1575 SEC 28 T29N R18W PT NW NW 3.346AC BEING Block/Condo Bldg: LOT 1 LOT 1 OF CSM 6/1575 & INC COM NW COR; TH S 00' E 272.88FT TO POB; TH N 8T E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 565.31 FT;TH S 08'E 226.37FT;TH S 87'W 28-29N-18W NW NW 595.49FT TO W LN; TH N 00'W 225.25FT TO POB (3.OOAC) Notes: Parcel History: Date Doc # Vol/Page Type 04/12/1999 601114 1418/114 AFF 04/12/1999 601113 1418/113 TD 07/23/1997 727/357 2006 SUMMARY Bill Fair Market Value: Assessed with: 149665 381,900 Valuations: Last Changed: 07/20/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.346 52,500 226,100 278,600 NO Totals for 2006: General Property 6.346 52,500 226,100 278,600 Woodland 0.000 0 0 Totals for 2005: General Property 6.346 52,500 226,100 278,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 12/0411998 Batch 516 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 15.00 Special Assessments Special Charges Delinquent Charges Total 15.00 0.00 0.00 Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ~y _L4111y~ SEC. T,~l N-R/YW ADDRESS ST. CROIX COUNTY, WISCONSIN I SUBDIVISION LOT / LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR; 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r P f ~ p2e/ r,v~ j i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ~tz,-el'- Elevation of vertical reference point: j G?n Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,kj Rear, O /-w feet From nearest property line Front, 0Side, 0Rear, 0 7 L~~ feet Number of feet from: well 6) building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE t . PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: 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: J ! Length: F1 / Number of Lines: Area Built: '~-;/'Z Fill depth to top of pipe: yl~} . Number of feet from nearest property line: Front, O Side, O Rear, Ft.,-,2 Number of feet from well: Number of feet from building: l (Include distances on plot plan). SEEPAGE PIT Size: -r~ Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box or distribution box 0 been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: rJ.T 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: C7t'/l Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HI1MAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7999 BUREAU OF PLUMBING MADISON, WI 53707 ' ❑ALTERNATIVE state Plan I.D. Number CONVENTIONAL ( lf assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTI DATE: ^ Thomas H. Cody R. R. 2, Box 180, Roberts, WI 54023 5--~4'd~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV NW NW, Section 28, T29N-R18W, Town of Warren, Lot#1 Nam, of Plumber. JMPIMPRSW No County. Sanitary Permit Number Thomas H. Cody 6593 St. Croix 64871 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKIN COV R / P O DED: PROVI D'. 1r- 120-i) 2ro• 9( YES ❑NO NO BEDDING: IVENTDIA / VENT MATL_ HIGH WATER NUMBER OF ROAD: PROPERTY/ WELL: BUILDING. VE TO FRESH ~,i l ALARM I FEET FROM / LINE AI wLE ❑ YES ` ICJ NO L` 1 ❑ ,E NO NEAREST ljly r`/J I✓ DOSING CHAMBER: MANUFACTURER BEDDING 11-11111111 CAPACITY PUMP MODEL. J PU MPiSIPHON MANUFACTl1R ER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PROPERTY WELL BUILDING (VENT T FRESH GALLONS PER CYCLE: PUMP AND co TROLS RATIONAL NUMBER OF NE AIRI N1- E T (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at th dept' f plwing N(;: H 1111AMIT111 MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH, LENGTH NO. OF DISTR. PIPE SPACIN(r . COVER INSIDE DIA -PITS LIQUID BED/TRENCH THE HES R1AL: i PIT DEPTH DIMENSIONS ""j T G GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. ISTR. NUMBER OF PR OPERTV WELL BUILDING'. VENT TO FRESH BEL( PFD ABUV COVER. ELEV. INLET ELE END. ~-7 L PIPS FEET FROM ,LINE AIR INLET'. ~r lJ d / / 2 f 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 MEASURED. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH. BED DEPTH OVER TRENCH: BED DEPTH OF TOPSOIL SQDDED SEEDED MULCHED CENTER EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO 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. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV. ELEV. DIA ELEV.. PIPES. DIA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES ❑NO ❑YES ❑NO COMMENTS: l PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF LRIOEERTV WELL: BUILDING: ❑YES ❑NO ❑YES ❑NO NEARESOM -I J~ Sketch System on R aqn county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R.01/82) Wisconsin APPLICATION FOR SANITARY PERMIT C COUNTY .(DILHR o6aRpTmenT OF (r~]LB 67) UNIFORM SANITARY PERMIT # InUUSTR V,LR130R6 HUTRn RELRTIOnS -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 PROP RTY OWNER MAILING ADDRESS 6[} PROPERTY LOCATION Cam: ~tf/V' "I/4, S T , N, R ( E (or W; To~wv 6A-GE: LOT NUMBER BLOC/K/ NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED )v 1 or 2 Family Number of Bedrooms. Li ❑ Public (Specify): THIS PERMIT IS FOR A: l New System ❑ Tank Replacement ❑ Repair El 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 Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: c'_ 7 r ` i iC t o.cr 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): f L~,) 2' Cj j( n1G' Private El Joint ❑ Public I, the undersigned, hereby assume responsibility for ins ,Nation of the private sewage system shown on the attached plans. Name of Plumber (Print): Sig tur } .M.WMPRSW No.: Phone Number: f Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 1 yt(j ❑ Owner Given Initial n.~ ~ ~C J ❑ 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 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 ~C~G~ Location of Property Section I t , T N - R W Township Mailing Address i Subdivision Name Lot Number', ' a ~ Previous Owner of Property w~A( Total Size of Parcel rte, ~'c t,`e5 Date Parcel was Created lti,_- X11 21 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No volume l~ and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: (:l:./ 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 I (We) een tl.6 y that ate 6-ta,tement,6 on .th" 6oAm are .t&ue to the but o6 my ( our ) hnow.tedge; that I (we) am (ate) the owner (6) o6 the property deal cAibed in .thiA in6o4nati.on 6onm, by vi tue o6 a wwvca.nty deed Aeeohded in the 066ice o6 the County Reg-i.e.teh o6 Deeds " Document No. , G ' Q ; and that I (we) pnea en tty own the pn.opob ed bite bon the sewage pob a76 yb.tem (on I (we) have obtained an easement, to Aun with the above duc i.bed pnopenty, 6o& the con,6tlcuati.on o6 6aid 6y6.tem, and the same ha6 been du, neeotded in the 066ice o j the County Re9.e6.ten o6 Deed6, as Document No. _40 666) SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 5y)1 DATE SIGNED DATE SIGNED H H a ST C- 105 r SEPTIC TANK MAINTENANCE AGREEMENT H 0 St. Croix County z 1 a OWNER/BUYER !,"/nn, Ci,r•~ ✓_J~ ROUTE/BOX NUMBER RA), &D '4 t 1~1_c` Fire Number CITY/STATE~G,; ZIP PROPERTY LOCATION:A/I-{,> 4, Section T .172--l-N, R /'R'-W, Town of k'o-tvk St. Croix County, Subdivision 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 II the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix. County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 E I/WE, the undersigned, have read the above requirements and agree 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. SIGNED DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. ~ O E >o a E° 0 c v c 3 0.- o c V cq c t .D O C$ CD (D V c O U U O -0 O)O C 010 ` 0 C cm O U m H 0O y c n L oC6 C N 0-0 :2 'a .O. - i W occ jc co 3010 ~j C'3 cv3~010 aEc Q - O y O cA f C = c0 O tt= c cti cm '0 0 0 C v n to ~ i O O O N C Lt C C N a - O N W °3vj,cn °O= o a N 3rn'L cu U) O c ° L ` C c~0 cc ~ U Q Q C 0) +L. O (D O Ln U) L 0 0 E U O Q D c,3FL-0 cn c`°~c0 UO. ~ C Co aL C ( N O _ O L O = 310Oa =urn 3~ V O N U M Q O i 0 N O j 0) (n a y O > Q CL CO co °oC c c~C: - (D 0 cu (U N ~ °v _ 0L ° ° LZ.c U O) C \ cu c L O O o co o 0) L c c cli 0) CD co N m p U `O E UO 0) .c C .L. L L- a) c _c rov~~oy° ~acu~ c N 3cnN 3° °oc° a 1- 0- a) a) 10 CL -C Z CL 13 D c a~ a 0) CD c u 0~ 0.0 v)- w z ca LL~a ~o c 0 cu i N C N N 3 `O O E cV of y w CU 3 m m N c cc w = N _J 0 [33 DEPARTMENT OF TY_& B'af_ VISION INDUSTRY, REPORT ON SOIL BORINGS AND b4SION ~P;. 60X,7969 H LABOR UMAN R AND ELATIONS PERCOLATION TESTS (115) ~{~C3A ON, Wi 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/IVIVIdICIPX~LTfy: LOT NO.:BLK. NO.: S IVISI NW 1/ 1/ 28 /DI N/R IQ E (o 1u~}Ev ~ COUNTY: /BUYER'S NAME: MAILING ADDRESS: 5{• C AOO /X TOM C o p y 0 3 L 'Q T5 1,()/' 's USE DATES OBSERVATIONS 'AVt i 1 NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCR~IPTIONS: PER ATION TESTS71 Residence ~e ,f/ ~ New ❑Replace I~{iJ~~~~ L . ~j~~ ZZ _~~j RATING: S= Site suitable for system U= Site unsuitable for system -S-4 -T l . CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) , DS ❑U ®s ❑u Qs ❑u Ds ou ❑s ©u ~oU~E~T~ i /Pj- le,)( Y6 F rcolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the r s.H63.09(5)(b), indicate: CG/fS s- Floodplain, indicate Floodplain elevation: PROFI LE DESCRIPTIONS OJ 4-).t C I'm h I- BORING TOTAL DEPTH TO GROUNDWATER- CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIF .__56_ TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B 93.1 G ' y a-6 y /v,~~ S' 7~~ /oily, S o . Iq 7Y' w- 6-f• T. . ' Tf, vE~ ' C s P 6-/e 17 s o ' 'TRti S1 B 3 T,-fN v C S /-0- 167' 064). s;/ B- ~'U70.(-0 , s~' TAN s/ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- ' Axe O 7V/j E L L SETT P- P L 2 G P P .~z 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. ~7gZ lye /u, l/- 107 SYSTEM ELEVATION < v f = %Y /il.X- NEXT 10 P6c.U.)RA- ~ a Eli Of 7'1O A) Td/b J~ p ► o - D 6) FT /3,4f~GitNDS APP . J WEST - O L or z-/ (0 3~ D 77 76' W .I, ~ .h • 8 70, PRaPc~I 36 -r r ~ ~ ; d F E 13.5 . ao i 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: GQ SEPTIC PLUMBING CO. *41a, 2 Z•- / l O S ADDRESS: RT, 3O'NEIL RD., HUDSON; WIS. 54016 CERLIF-ICATION NUMBER: PHONE NUn~ ER (optional): ROBERT ULBRICHT j a L y~~- 3~(p 3 WIS. MASTER ' ' ' CST SIGNATURE- WAN. INSTALLER & DESIGNER UC. NO. 00663 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. • ~nG 1 s DILHR-SBD-6395 (R. 02/82) - OVER 5-1-7 2S ROHL & TIMM EXCAVATING DDB To r-i f oci J Z 310 Arch Street SHEET NO. OF HUDSON, WIS. 54016 CALCULATED BY DATE (715) 386-8664 CHGEo'. / ~ DATE SCALE 1` ✓ h ► ~ye CL= lab O` n et~ )oi oc PRODUCT 204-1 ~M: Ina. Groton. Mass. 01471. JOB '10fii ,.'4 f+ ROHL & TIMM EXCAVATING G 310 Arch Street SHEET NO. OF • HUDSON, WIS. 54016 CALCULATED BY DATE (715) 386-8664 er~ Y DATE_ SCALE 'I n~ring Wet 11 916~ PRODUCT 2041 ~E as7 Inc., Groton, Mass. 01471. O 41 w L C O O _ 0 C7 CL ~ c Lf7 ~ ; E E F- 00 c o_c ~0 u a oc_ E o Q c 'a- CD y cm cQ o .t c,E E 0 W rn . c- E ° mL 10 a ° > CL c o N 0 ~ ~o occ c N O` a m :t c N ~ r ~ d V E ° °d ` CL m v 5 n o E H G m r ` E E E ' `m r O M cC > w 7 O > i0 y> LL Y d O *a w cc "6 WS 2 E .2 VE W aE a~°'A 1Oi L` aE o 0 O °E o w J . N a cEro c~ ;u CL mw .'Cc 'E tV w ,,t0c m -c~ a~a od I / FL-~c Ha ~2 Ud ¢ L o --a w d > u m ° u ar E D l 0 Z -2 u„od _ IS . CL w w z Z O U z LL ~ ~o Z U o ° w 00 I MCC CC D o~ 0 mmmi F-- U) 0 U) C3 co Z D ° Q 0 O z U) N cim O U U j K = C'3 J U Y Q OJ 2 Z) 0 C) LL ___I MCC w U N U) co w w U) cn or > w p F Crr ll. J C= to ao a : m w Z ` O w co sac ~ m z U) ~ o ° O = O ci z Q WISCOnS1n R APPLICATION FOR SANITARY PERMIT UJ DILH COUNTY (PLB 67) oEaaRT~ nEnT of UNIFORM SANITARY PERMIT # InOUSTRV,LRROR&HUMRn RELRTIOnS • Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 114/Vinches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS ~lq Cop/ ',~o%6 600 7--5;7 s . PROPERTY LOCATION C!TY0 W Z V 6144 1,E1V !v 1 /4 A01 /4, S , Tt/, N, R ld E (or W To OF: LOT NUMBER BLOCK UMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ,4 ,l3fjDG.f~vDDs ~ dL Al. -4- TYP OF BUILDING OR USE SERVED y lee) 1 or 2 Family Number of Bedrooms. / Public (Specify): o< < / THIS PERMIT IS FOR A: I New 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. A Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressur ❑`Vault Pri ❑ Pit Privy Existing, For Which A Previous Permit Is On File, Per it # issued ❑ An Existing System That Has Been Inspected And Is ompliant As Far As Soil onditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete nstructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: rev L / IF THIS IS AN ALTERNATIVE SYS Ef COM L TE THIS OLOC ❑ Mound ❑ In -Ground Pressure Total #of! Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber F Manufacturer: PERCOLATION RATE ABSO 1 . ION AREA AB ORPT AREA WATER SUPPLY: (Minutes per inch): ~jREQUIR D (Square Feel): PROP SED (Square Feet): !3 d ~y r r le Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for stallation of the private sewage system shown on the attached plans. Name of Plumber (Print) Signat MP/MPRSW No.: Phone Number: alt COO ! 1*EZtX_,Szi3 (?ij 0Yc(-33sy PI ber's Address: Name of Designer: -COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved C1. ~ ✓1 ~~f • / / 7 r- ❑ Owner Given Initial 'J / 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 v r N x m m 4 rQ3 V Vi w D cD CD << O 7 N *oa ~co00mo Go 3 ~Ft 0 3 c cn to Ti o~zD "0 ? cufDi m &o W 0 a Q 0 ID 0 0 tD =1 tD m*m° -"6V,W 0 v = cu CD cn < N $ CD - 0 m 0 cD n 3 . ooooo a 0 3 Ca oms C: owot° > > O co 0 o a 00 3 0 c c c a CD M' cn 7D 0 w CO D c n < y 1 o Dco Q j c~ o o c c _ a c "I w 0 w o a Q w Z5 0 m = cn ti m 9~ FIT N C ~ Z 0 CD U) o - D aCDo CD CD 0 =r CD 3~mcu~a D n ocm ?~'f°~ "4 o ~oaa ~cow0 M Q cn cD CD 0 a tDN~ao ?moo Nvo,w~cD~ C ft1 m m c 5 o a~ C v=r \ M ~ 1 \ / ao w m v w 2 f' -0 0 o< cc > vl nod c~nCC 0a m i g OL 0. 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