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Parcel 006-1075-30-000 01/06/2006 11:15 AM
PAGE 1 OF 1
Alt. Parcel 33.31.16.510C 006 - TOWN OF CYLON
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
CHARLENE WEEKS O - WEEKS, CHARLENE
1828 CTY RD O
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 1828 CTY RD O
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 7.100 'Plat: N/A-NOT AVAILABLE
SEC 33 T31N R1 6W PT E1/2 SW 1/4 DESC AS block/Condo Bldg:
BEG INT S R/W RR & W R/W RD, TH W 255',
SWLY ON ELY LN RR TO N LN VILL CYLON, E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
437 1/2 FT, N 200', E 149' TO RD N TO 33-31N-16W
POB
Notes: L Parcel History:
w , LS/~~_ U Date Doc # Vol/Page Type
05/05/2003 720135 2230/105 EZ
07/23/1997 1042/513 PR
07/23/1997 1042/511 TI
07/23/1997 535/73
2005 SUMMARY Bill M Fair Market Value: Assessed with:
637 82,600
Valuations: Last Changed: 09/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 7.100 25,000 47,000 72,000 NO
Totals for 2005:
General Property 7.100 25,000 47,000 72,000
Woodland 0.000 0 0
Totals for 2004:
General Property 7.100 25,000 47,000 72,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 006-1075-40-000 01/06/2006 11:20 AM
PAGE 1 OF 1
Alt. Parcel 33.31.16.51 OD 006 - TOWN OF CYLON
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
LATON N & RANAE J HENDERSON O - HENDERSON, LATON N & RANAE J
SAMUEL C C - ERICKSON SAMUEL C
ERICKSON
1790 220TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Aches: 1 6.400 Plat: N/A-NOT AVAILABLE
SEC 33 T31 N R16W PT S 1/2 NE SW SLY & Block/Condo Bldg:
WLY OF RR(
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-31N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1114/80
2005 SUMMARY Bill Fair Market Value: Assessed with:
638 1,100
Valuations: Last Changed: 09/09/2004
Description Class Acres Land Improve Total State Reason
UNDEVELOPED G5 6.400 1,000 0 1,000 NO
Totals for 2005:
General Property 6.400 1,000 0 1,000
Woodland 0.000 0 0
Totals for 2004:
General Property 6.400 1,000 0 1,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 006-1075-50-000 01/06/2006 11:20 AM
PAGE 1 OF 1
Alt. Parcel 33.31.16.510E 006 - TOWN OF CYLON
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 - RUTLEDGE, GAIL R
GAIL R RUTLEDGE
1819 226TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1819 226TH ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.650 Plat: N/A-NOT AVAILABLE
SEC 33 T31N R16W.65AC IN E 1/2 SW1/4 Block/Condo Bldg:
COM 66'N OF NE COR LOT 6 BLK 6 VIL
CYLON, TH W 142'N 200' E142' TH S 200' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
TO POB 33-31N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/13/2005 806291 2887/188 QC
05/05/2003 720135 2230/105 EZ
07/23/1997 707/602
07/23/1997 535/
more...
2005 SUMMARY Bill M Fair Market Value: As ss ith:
639 24,700
Valuations: Last Changed: 09/09/2004
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 0.650 1,500 20,000 21,500 NO
Totals for 2005:
General Property 0.650 1,500 20,000 21,500
Woodland 0.000 0 0
Totals for 2004:
General Property 0.650 1,500 20,000 21,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 006-1075-50-001 01/06/2006 11:20 AM
PAGE 1 OF 1
Alt. Parcel 33.31.16.51 OF 006 - TOWN OF CYLON
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 - SOO LINE RAILROAD
SOO LINE RAILROAD
SOO LINE BOX
MINNEAPOLIS MN 55440
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 3.050 Plat: N/A-NOT AVAILABLE
SEC 33 T31N R1 6W 3.05 ACRES RAILROAD IN Block/Condo Bldg:
NE SW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-31 N-1 6W
Notes: Parcel History:
Date Doc # Vol/Page Type
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/15/1988
Description Class Acres Land Improve Total State Reason
OTHER X4 3.050 0 0 0 NO
Totals for 2005:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 0 0 0
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
Total 0.00 0.00 0.00
Parcel 006-1075-70-000 01/06/2006 11:21 AM
PAGE 1 OF 1
Alt. Parcel 33.31.16.511 B 006 - TOWN OF CYLON
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
LATON N & RANEE J HENDERSON O - HENDERSON, LATON N & RANEE J
SAMUEL C C - ERICKSON SAMUEL C
ERICKSON
1790 220TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 16.950 Plat: N/A-NOT AVAILABLE
SEC 33 T31N RI 6W S1/2 NW SW EXC RR Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-31N-16W
Notes: Parcel History:
WD 2575-161 BAD LEGAL--LEFT AS IS UNTIL Date Doc # Vol/Page Type
DEED COMES W/ BETTER DESCRIPTION--NOTES 05/19/2004 763018 2575/161 WD
ON DEED FOR REFERENCE. 05/03/2005 07/23/1997 1114/80
2005 SUMMARY Bill Fair Market Value: Assessed with:
641 Use Value Assessment
Valuations: Last Changed: 07/26/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 6.000 900 0 900 NO
AGRICULTURAL FOREST G5M 10.950 3,300 0 3,300 NO
Totals for 2005:
General Property 16.950 4,200 0 4,200
Woodland 0.000 0 0
Totals for 2004:
General Property 16.950 7,400 0 7,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 006-1075-80-000 01/06/2006 11:21 AM
PAGE 1 OF 1
Alt. Parcel 33.31.16.512 006 - TOWN OF CYLON
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
LATON N & RANAE J HENDERSON O - HENDERSON, LATON N & RANAE J
ERICKSON SAMUEL C C - ERICKSON SAMUEL C
1790 220TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 34.830 Plat: N/A-NOT AVAILABLE
SEC 33 T31 N R1 6W SW SW EXC PT TO CSM Block/Condo Bldg:
9/2635
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-31N-16W
Notes: Parcel History:
WD 2575-161 BAD LEGAL--LEFT AS IS UNTIL Date Doc # Vol/Page Type
DEED COMES W/BETTER DESCRIPTION---NOTES 05/19/2004 763018 2575/161 WD
ON DEED FOR REFERENCE 05/03/05
07/23/1997 1114/80
2005 SUMMARY Bill Fair Market Value: Assessed with:
642 Use Value Assessment
Valuations: Last Changed: 07/26/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 17.830 3,200 0 3,200 NO
AGRICULTURAL FOREST G5M 17.000 8,500 0 8,500 NO
Totals for 2005:
General Property 34.830 11,700 0 11,700
Woodland 0.000 0 0
Totals for 2004:
General Property 34.830 20,200 0 20,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Parcel 006-1075-30-000 07/21/2005 02:16 PM
PAGE 1 OF 1
Alt. Parcel 33.31.16.510C 006 - TOWN OF CYLON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
CHARLENE WEEKS " WEEKS, CHARLENE
1828 CTY RD O
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1828 CTY RD O
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 7.100 Plat: N/A-NOT AVAILABLE
SEC 33 T31 N R1 6W PT E1/2 SW 1/4 DESC AS Block/Condo Bldg:
BEG INT S R/W RR & W R/W RD, TH W 255',
SWLY ON ELY LN RR TO N LN VILL CYLON, E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
437 1/2 FT, N 200', E 149' TO RD N TO 33-31N-16W
POB
Notes: Parcel History: 4t
Date Doc # Vol/Page n Type
05/05/2003 720135 2230/105 EZ
07/23/1997 kPR
07/23/1997 Mt ctn~.,,Tr-o
07/23/1997 rSZ 53 ~ ~Y ~ _ v-e--
2004 SUMMARY Bill Fair Market Value: Asses a with:
53003 70,800
Valuations: Last Changed: 09/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 7.100 25,000 47,000 72,000 NO
Totals for 2004:
General Property 7.100 25,000 47,000 72,000
Woodland 0.000 0 0
Totals for 2003:
General Property 7.100 17,000 39,700 56,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 512
Specials:
User Special Code Category Amount
073-DELQ GARBAGE DELINQUENT CHARGE 66.00
Total Special Assessments Special Charges Delinquent Charges
0.00 0.00 66.00
Form - S T C - 104
' I
AS BUILT SANITARY SYSTEM REPORT
OWNER f1Y~' , y tea TOWNSHIP SEC. T,31 N-R_Z(,,_W
ADDRESSy ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE ~(1 Q~
PLAN VIEW
Distances and dimensions to meet requirements of ILH-R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
e\ t
TJVar
9f) I
INDICATE NORTH ARROW
w C ~41
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: p-Zo ` Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: kt4-6
Number of rings used: Tank manhole cover elevation:
T6 15-
Tank Inlet Elevation: 7 Tank Outlet Elevation:
Number of feet from nearest Road:
Front,k4okSide10 Rear, 0 feet
From nearest property line Front,0 Side ,Q Rear, O feet
Number of feet from: well ~building:
(Include this in ormat'4on of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: U)(C-- Jj 5 Liquid Capacity:
Pump Model: (2GAAA Pump/Siphon Manufacturer: yl. 0,3 4. Pump Size
Elevation of inlet: 9 `~5~ Bottom of tank elevation:
7
Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front,(&Side, O Rear, Ft.~d
Number of feet from well:
Number of feet from building: (7~'
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth tol'top of pipe:
Number of/'feet from nearest property line: Front, O Side, O Rear,O Ft.
Number of feet from well:
Number of feet from building:
/EEPAGE nclude distances on plot plan).
Si ze: Number of pits: Diameter:
Liquid dep Bottom of seepage pit elevation:
Area B It:
Has eit r a drop box O or di,%Eribution box O been used on any of the above soil
abso tion sytems? (Check on,0.
H DING TANK
Manufacturer: Capacity:
Number of ings used: Elevation of bottom of tank:
Eleva ion of inlet:
N ber of feet from nearest property line: Front, O Side, O Rear, OFt.
/ Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: - Plumber on job ;n
License Number:
3/84:mj
r'
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS
DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
❑ CONVENTIONAL ALTERNATIVE slalePlan l o N mbe,
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound IIf d551
84007
7328
NAME OF PERMIT HOLDER. A I
DDRESS OF PERMIT HOLDER: ,
INSPECTION DATE.
Archie Johnson R. R. 3, New Richmond, WI
BENCH MARK IPermanem reference point) DESCRIBE IF DIFFERENT FROM PLAN.
~REF.
PT. ELEV.. C~FLEV
NE SW, Section 33, T31N-R16W, Town of Cylon
Name of Plumber. MP/MPRSW No. County
am~ary Permil Number:
Gary Steel 3254 St. Croix 58895
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKIN C ER
LJ e eA- 5 O V l ~7jOff. 3I PROV DES PROM D-
7 YES ONO Y S, ONO
BEDDING: VENT DIA. VENT MATL HIGH WATER NUMBER OF ROAD. ' PRfff~~Oi~PERTY WELL BUILlIM13 VENT TO FRESH
C ALARM. FEET FROM ✓ O 4", e7 T~ IAIR INLET.
OYES O OYES ONO NEAREST -f
DOSING CHAMBER:
MA'NUFFA~CT~URRER/~ BEDDING: LIOUID CAPACITY PUMP MODEL-) PUMP/SIPHON MANUF ACTIIREH WARNING LABEL LOCKING COVER
W ~/rf % OYES NO o O ~.e oPROVIDED. PRrtOvVIDED:
r C21=4 ES ENO I VENT Ta FRESH
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL YES ONO SY ES NO
NUMBER OF PROPERr WELL EuILDIN
(DIFFERENCE BETWEEN FEET FROM LI"~o / J p f
PUMP ON AND OFF) (`l KYES ❑ NO NEAREST L (j
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I FNCITH DIAMFTER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease unti=FORCE Z
the soil is dry enough to continue.) , Q
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING ER INSIDE DIA SPITS LIQUID
DIMENSIONS TRENCHES ERI L PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR PIPE DISTR. PIPE MATERIAL: ISTH. NUMBER OF
B E E S ABOVECOVER. Et EV INLET E
LOW PIP. LEV. END PROPERTY =V-VELLBUILDING. VENT TO FRESH
Es FEET FROM LINE AIR INLET
_ NEAREST-s
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-
O YES O NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE =E1Y RS :TO ERVATION WELLS
DEPTH OVER TRENCH BED DEPTH OVER TRENCH/BED ONO OYES NO
CENT ER DEPTH OF TOPSOIL SODDED SEEDED MULCHED
EDGES
OYES ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS 3 S 3 / .S
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND EL /09 25 E jv DIA EL E09 a
STRIB J PIPES Dla > J
DIUTION V W
HOLE SIZE HOLE SPACING DRILLED CORRECTLY
/ COVER MATERIAL
INFORMATION VERTICAL LIFT CORRESPONDS TO APPROVED
/ 3 PLANS.
YES NO I,YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING.
FEET FIR
YES ❑ NO LS ES ❑ NO ]NEARESM--~ ~T/
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE-.
DILHR SBD 6710 (R. 01/82)
wisconsin APPLICATION FOR SANITARY PERMIT
(r DILHR ~--X COUNTY
- OEPRRTfT1EnTOF (PLB 67)
inOUSTRV,LABOR 3HUMAnRELRTIOns UNIFORM-4$ANITARY PERMIT #
-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 MAILING ADDRESS
(
Eno 3 1
PROPER LOCATION GC/
006.1/4,S (,t)1/4, S , T I, N, R S(or) W TOw O :
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK
STATE PLAN I.D. NUMBER
~o v 73
TYPE OF BUILDING OR USE SERVED
A 1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
❑ Re I ement Soil Absorption System ❑ Revision ❑ Privy
AIrerna e ystem ❑ 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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #bf Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity Zyi
Lift Pump/Siphon Chamber C)
Manufacturer: Zc?
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
198 a d)n _ '0 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of P mber (Print): Signature: Mf}/MPRSW No.: Phone Number:
Plumber' Addr ss: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
[Sig]nature of Issuing Agent: Fee: Date:
, ❑ Disapproved
f L~ Owner Given Initial
S~"14 ' - - Fi 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.
1
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STATE OF WISCONSIN DILHR
LHR PRIVATE SEWAGE SYSTEMS BUDIVRIESIO 1NoF LUFNA ING BUILDINGS
• ° s - ° 201 E. Washington Avenue, Rm 141
PLAN APPROVAL APPLICATION P.O. Box 7969, Madison, WI 53707
608-2663815
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 Submitting Party (Plans returned to same) Project Name
l~04y,-/ L. ZtFE ~ e, I
Street & No. or Rural Route Project Location - Street & No. or Legal Description
EYA / 3
City or Village State zip City ❑ County
Village ❑ OF:
4/
F C.r/ Ci~ l ` • l 0 / Town
Telephone No. (Include area code)
/5- Al L zoo
Designer Telephone No. (Include area code) Owne Name Telephone No. (Include area code)
S -387
1 5 t) n
Street & No. Street & No. koor
i
City or Village State Zip City or Village State 1 Zip
7 G(/ 1. /
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 - 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. ! a
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.
op
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 reviev:: 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 r
DILHR-SBD6748 (R. 03/84) Effective July 1, 1984 -OVE
~S
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Towns hip /fl?d}dC
NE SwJ is 33 IT 31 N/R 16 VV0 C ton St. cuix
Street Address: Subdivision: County:
Landowners Name: Mailing Address:
A,,Lchie Johwson R. R. 1, New Richmond, WT 54017
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 hs
access to the above described premises at any reasonable time for the"..urpoos
s~e
of inspection the construction of or monitoring of the system. I fur " rla$f} ~
to either personally or by my agent contact the proper county offici~i-'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 be
obtained. 80en
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 ofr A* icant Date
STATE OF WISCONSIN Subscribed and sworn to before me
`r5 S • ~
COUNTY OF
This day of 19,E
Notary Public, State of Wisconsin
DILHR-SBD-6413 (N. 05/81) ~2 ! My Commission Expires: I
ST. CROI X COUNTY
~WI SC0 N S I N
z ZONING OFFICE
#f-='
796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
OctobeA 8, 1984
Division ob Satiety and Buit-ding
Bureau ob Plumbing
P. 0. Box 7969
Madison, GUI 53707
Dean Sit:
An on-site investigation bon the Anch.te Johnson ponpetc.ty focated at
the NE-14 ob the SM-4 ob Section 33, T31N-R16W, Town o() Cy2on, St. Croix County,
tLeveaXed su.itabte soitts at a depth ob 2.50 beet, below which seazonabte
high ground watelt was noted.
This rsite shoutd be su.itabte bon a mound system.
Showed you have any questi.onz, ptease beef ()nee to contact this
obbtice.
Sincetety,
Thomas C. NeEson
Ass scant Zoning Admi isttcatot
TCN/mi
f;ECEI W `
f( 15198-
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. Crsoix
Location NE 1/4, SW 1/4, Sec. 33 T 31 N, R 16 SX"Kr W
Town d4X*f&PA ~ Cyfon Street Address
Lot No. Block Subdivision
Landowner's Name: Anchie Joh"on
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:
❑ to have one of the first five approvals guaranteed for this year. This is
number - - of those a,ir'li,atlons. (Use one of the first five
quota numbers i ueTto you.)
one of the applications needing a quota number. The quota number assigned to
this application is 59 - 09 - 5
❑ for one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
❑ for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria establish 1 c~
department.
❑ for an application on file prior to February 1, 1980.
❑ for a lot that meets the criteria for a conventional private sewagets~ystem.
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 lot meets the criteria for a
conventional private sewage system, check here. E]
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Net,5on Si u
County Official
Title A66iztant Zoaing AdminiAysatort Date Octobers 8, 1984
DILHR-SBD-6158 (R 12182) ,t/
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
',tiDUSTi3Y, c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 76
HUMAN RELATIONS
ON, WI 3707
(H63.09(1) & Chapter 145.045)
LOCATION: W: SECTION:T3 D J6 W TOWNSHIP/MNAIEE+P4t {FV LOT NO.:BLK NO.: SUBDIVISION NAME
COUNTY: OWNES'S/Bt teWS NAME MAILING ADDRESS
USE DATES OBSERVATIONS MAD
-
esidence NO BEDRMS.: COMMERCIAL DESCRIPTION: PRO_FILE DESCRIPTIONS: ER OLATION TESTS:
1R -
New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVE N-
NTIONAL: MOUND: IGROUNDP--R E: SYSTEMFILLHOLDING TANK: RECOMMENDED SYS fEM:(option-a
DS ~U UZS ❑U- ES U os U [:Is U
Percolation Tests are NOT required DESIGN RATE If any portion of the tested area is in the
uder s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS /
'9 BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, C LOR, TEXTURE, AND DEPTH
NUMBER 6EPTttIN• OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
113-
i'
I e ~ ~L
,
4 _ F
B
;c CL+,I_>,w. r ~t
B- I
B I }
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVELI-INCH t RATE MINUTES
;UMBER 14\1GHES AFTERSWELLING INTERVAL-MIN. PER INCH
I C _ -
P
L . _ - - -
?LOT PLAN: Shown locations of percolation tests, soil borings and the dimensions of suitable soil areas. indicate scale or distances. Describe what are the hori
,rental and vertical elevation reference points and show their location on the plot plan, Show the surface elevation at all borings and the direction and oercen,
!and slope
SYSTEM ELEVATION %r'-
OPTIONAL WORKSHEET
1. MOUND SYSTEM r, II. IN GROUND PRESSURE SYSTEM -Continued,
1. Wastewater Load, Total Daily Flow= 00 gal. 10. Force Main:
Use section H 63.15 (3) (c), Wis. Minimum Dosing Rate = 4~-' gpm
Adm. Code and PROVIDE A DETAILED Diameter in,
LIST OF SIZING ON PLANS. 11. Total Dynamic Head:
2. Depth to Limiting Factor = 2 ft. System Head 2 5 ft.
3 Landslope = n- % Vertical Lift = 1~ ft.
4 Distance from Dose Chamber to Friction Loss = ft.
Distribution System r ft. TDH ft,
5. Elevation Difference Between 12. Pump Selection:
Pump and Distribution System It. Pump will d' charge at least .L' gpm
6. Absorption Area Sizing: at ft. total dynamic head.
Area Required = ^ sq. ft. Pump model and manufacturer.
fi7 q ~"L
.4IiL
Bed or Trench Length (B) = ft.
Bed or Trench Width (A) _ Cz_1 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
Fill Depth Downslope (E) _ Z ft. 4 Doses in 24 hrs. _ gal.
Bed or Trench Depth (F) = ft. Backflow = gal.
Cap and Topsoil Depth (G) = ft. Minimum Dose = gal.
Cap and Topsoil Depth (H) - ft. 14. Dose Chamber:
8. Mound Length: Volume =X gal.
End Slope (K) ft.
Total Mound Length (L) = G ft. III. ONVENTIONAL PRIVATE SEWAGE SYSTEM
9. Mound Width: I. Wastewater Load, Total Daily Flow = ~al.
Upslope Correction Factor Use section H 63.15 (3) (c), Wis.
Upslope Width (J) = ft. dui. Code and PROVIDE DETAILED
Downslope Correction Factor = LI OF SIZING ON PLANS.
Downslope Width (1) = 1Q_ ft. 2. Require eptic Tank Capacity = gal.
Total Mound Width (W) ft. 3. Percolation to = 4A:_1YGty " min./in.
10 Basal Area: 4. Absorption Ar Sizing:
Infiltrative Capacity of r7u Refer to Table in chapter.HOT~,/
Natural Soil = gal./sq.ft./day and PROVIDE A ETAILED t,l<T OF
Basal Area Required = sq. ft. SIZING ON PLANS.
Basal Area Available = sq. ft. Required Area = sq. ft.
i I. If Standard Tables from Chapter _ Length ft.
H 63 are Used, Indicate Table No. Width = ft.
12. For the Distribution Network, Use Numbers 5.14 in Section 11. Number of Trenc¢es
Trench Spacing." ft.
11. IN-GROUND PRESSURE SYSTEM S. Distribution System:
De smiting Factor - ft. Lateral Length = ft.
an _ -
t. Landslslope = ~ o Number of Laterals
=
_ in.
Percolation Rate_ min./m. Lat a Spacing
4. Pro d System Elevation = ft. Distance from = in.
Wastewater Load, Total Daily Flow: gal. System Elevation = fit.
Use section H 63.15 (3) (c), Wis.
Adm. Code and PROVIDE A DETAILED IV. SYSTEM-IN-FILL
LIST OF SIZING ON PLANS. Fill in A11 Items from Section Ili
Required Septic Tank Capacity gal.
6. Absorption Area Sizing: V. SEPTIC TANK
Percolation Rate = min./in. 1. Capacity = G gal.
Area Required = sq. ft. 2. Manufacturer:
System Length = ~z ft. 3. Show Site Constructed Tank Details on Plan
System Width = 7_ ft.
7. Distribution Pipe Sizing: VI. DOSING TANK r r
Hole Siie = yl- in. 1. Capacity g:+l
Holc Spacing - c_ '-Z It. 2. Manuraciurer. J-
Lateral Length 20 it. 3. Pump Manulaclurer:
t_alcral Siic in. 4. Pump Model: \A) C~ -
I dleral Spacing) It. S. Operating Head
Distdncc Irons Sidcwdll to I'ipc in. b. I low Rate- 312 /Z gpm.
8 DislribUlion Pipe Discharge Rile: 7- Show Site Constructed Tank Details on Plans
Number of Ilolcs 1'ei Pipe
I low Per Pipc C' 1 glun. VI1. H"LUING 1 A N K
9. Manilold Siting: I. Cap:-reify - - gal.
I ypC (CCotC1 or cod) 2. MJnUI dl1Ul'Cr:
Length = IL 3 Show Site Constructed Tank Details on PI16s
Diameter = - in.
-SHOW ALL INFORMATION ON PLANS-
DILHR SBD-6761 (803/82) -123-
1,'777
I
I
j%G
PLOAS
EID
® p HUMAN REtA~w
!1'~ tA80R AND ~ ` A
INDUSTRY, AND ltD1N~s
DEPARTMtaT D~ DF SAF. ~ ~ , j -
SPONpENCE,
EE CORRE
1 0~ 4 r
/ - - y,
.o
I o~ ~?oogAl (3;m
I E'er n"
r-.,-
a 7328
10
i
3 _
ryy0b,i~ ~s,y
Page Of
Straw, Marsh Hay, Or
Synthetic Covering
Distribution Pipe
Medium Sand
H - - - G
Topsoil
F
E D
3
PL
~ Slope
I-
Bed Of -2"-2% Force Main Plowed
ate From Pum
La er
p
Y
1NDUSSRY, LABOR AND ►LD►N6S REI 9
fDEPARIV01" Of OF sAF } AND D / Ft.
EE CORRESpotiDENc6ross Section Of A Mound System Using E OC Ft.
A Bed For The Absorption Area F Ft.
r G_Ft.
A Ft. Ft.
Signed.
B ~ z Ft. C~
License Number: I(
Date: L 6z. Ft.
j Ft.
Q
Alternate Position T Ft.
of
Force Main W Ft.
L
d Observation Pipe
B K
A I.----------------------
-'I
r Force Main
w to ,~,-T~--Y------,----- ~,Distribution Bed Of 2 - 2 '2'~-
Pipe Aggregate
I
Observation Pipe Permanent Markers
Plan View Of Mound Using A Bed For The Absorption Area
-114-
.#,q
Page Of
Perforated Pipe Detail
1 ~ End View
Perforated
End Cop -.r PVC Pipe
~pS`occe Holes Located On Bottom,
2
Are Equally Spaced
\\/~/Q S f iv;
* PVC Force Main C 7`~ L1
~Q PVC
Manifold Pipe
Alternate Position Of
Distribution
pLrJNyg1NG Pipe ~I Force Main
.Li
~ast H I i nd CapI 4()V,328
E HUMAN REl Sbution Pipe Layout
AND .
All ATW~ P 0 Ft.
LABOR D gull INGS S] R .r
INDU gAFETY.
pEPARTMENbwskoN S
`
• oNpE~C~, ~n If,
CORR~SP X InchpS
Y f~ Inches
Signed: Hole Diameter Inch
Lateral / Inch(es)
License Number: Manifold 2 Inches
Date: , Force Main Inches
# of holes/pipe
Invert Elevation of Laterals 3Ft,
-116-
PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VENT CAP
`1 C.T. VENT PIPE
WEATHER PROOF APPROVED LOCKIRIG
JUNCTION BOX MANHOLE COVER
25' FROM DOOR,
WINDOW OR FRESH 12"MIl1.
AIR INTAKE
GRADE
I 4'MIN.
4/1
iB"MIN.
COIJDUIT
18"MIN,
PROVIDE I T AIRTIGHT SEAL I I I < ~
PLUMBING
APPROVED JOINT A APPROVED JOIIJTS
W/C.1. PIPE (j ii / I III /C.I. PIPE
EXTENDfNG 3' ~ I II ,ALARM EXTENDING 3'
AIL Wm p V rm*
0~3TO SOLID SOIL. B > v I I UNTO SOLID SOIL
RELATIONSI I >
;`4
DEPARTMENT OF 1NDU TRY, LAB DA BD N NGS o Q
G7 C DIVISIO SAFETY !
LLEV, FT SEE C0RRESP0NDENe4MP - OFF
CONCRETE BLOCK
RISER EXIT PER.MITFED GNL`J IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPEC.IFICATIOUS 1640®
DOSE
TANKS MANUFACTURER: ° NUMBER OF DOSES :-J -PER DAy
TANK SIZEGALLONS DOSE VOLUME
ALARM MANUFACTURER: INCLUDING BACKFLOW: GALLONS
MODEL NUMBER: CAPACITIES: A= IIJCHES OR GALLONS
SWITCH TYPE: B IIJCHES OR"GALLON}S
PUMP MANUFACTURER: r-= NCHES OR GALONS
MODEL NUMBER: C D= IMCHES ORS L'~ =GALLONS
SWITCH TYPE: DOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE `I Z GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE._(_o_' FEET
+ MINIMUM NETWORK SUPPL'~ PRESSURE . . , , , . . 2.5 FEET Z Z , t cr+ ,
4` L
F y
+ -)LC-- FEET OF FORCE MAIN X ' U ~or FRICTiOQ FACTOR.. FEET ~X R X
TOTAL DYNAMIC HEAD _ 3E4 FEET
~.,_.~.I,-' I r Ifs
INTERNAL DIMENSIONS OF TANK: L-Edl&`H `t ;WIDTH 6LIQLIID DEPTH
C%
SIGNE DC~=-- 't` LICE S IJUMBER'. _117_.
Model ~~yy
. UU 70"--n fb a Efflucmt Pumps
3 ate,
120
~A
~s
ffi 100 yA
PLUMBING
• m ~add iaHa
APPROVEI
r
I!'p
E DEPARTMENT OF INDJTRY, LABOR AND. nrL`,TI^NS
s.yp DIVISIO) SAFETYf IND BIjWDi~duS
0 66 SEE CO *,PONDENCE
yp
r 15 J'j C,
`XPM03. 'h H.P.
20 WP03, 'h H.P.
a 20 ao I so 80 100 120
Gap>yc"1y -Gallons Per M!•iute
Mm WIL
Amw Rpm
V6 rl~ 3.
1~5' 9.4
_ WF ,.i17E tTyJ 5t
WPFf'!;il?E 230 10 4.7
WPhb5~1E. 115 -369 >
h _ WPH05i 230 8.0
WPH0532j: 206/230 - 3.4 60
WPHOS34E-'460 3m
_ 1.7
W?H0712E 2-30 10 9.0
3% WPH0732E 206/230 5.4
_WPHO734E 460 30
2.7
WPH1012E 230 10 11.8 X 70
s 50 3;.. ,
1 WPH1032E 208/230 6.4 3,0 - WPH1031E-
. fY 460 3.2
WPH1512E 230 10 13.3
WPHtS.'2E 208/230 9.2
W PH 153, E 460 30 4.6 80
th -
_ WPHH1512E 230 1,0 13.3
vVPHH15$2E 208/230 9.2
{~J WPHH1534E •460 30
4.8
SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOVT NOTICE
3
0)
PLAN APPROVAL Safety and Buildings Division
Bureau of Plumbing
DI LHR P.O Box 7969
N.u,
53707
eneral Plumbing Plans Madison, wl
G
y~ Private Sewage Plans Telephone: (608)266-3815
OFFICE USE ONLY
Plan Identification No.
CT~ b^y S ~2 E'_ / Gallons Per Day
g88Ill/, shore- Di-
' Y C c.xl--I eJ d V l' ` PRIORITY PLAN REVIEW ONLY
Plan Review _
$ / e~,
Petition For Modification
$
Project Name Project Location - Street No. or Legal Description
/7 rG IL4- S W,, 33, 3 i 16 W
County
El city El VillageQ Town of: e v /0 j
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 approva
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.
X FOR PRIVATE SEWAGE PLANS: 3 G~C6~
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 ♦ /~l /~-4
cc: OWS ❑ DPS ❑ H&R & Rec. San. Section
County ❑ Local PI ❑ Facilities Need Analysis Se(
❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture:
DlLHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other
NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IG DIVISION
D PERCOLATION TESTS (115MADISP.O. BOX 76
ON WI 53707
LATIONS
(H63.09(1) & Chapter 145.045)
SECTION: TOWNSHIP/PA~E+P,~4t+~Y: FL T NO.: BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNE 'S/B' S NAM MAILING ADDRESS:
_USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence WNew ❑ Replace -
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
E ]S Zu s au 1, 1 ❑ s pu ❑ s Z u a s z u
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
r , PROFILE DESCRIPTIONS J
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TE TURE, AND DEPTH
NUMBER BEPFt#1(N, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
&
B- ~2
B
B-
B-
B-
PERCOLATION TESTS
~ J i r?~R►'
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IdNGHfSS AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
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.
SYSTEM ELEVATION
3
=
60
r
N
GU- 9,4~it^s _
'SEC, 33 _
r + (
a 3~
A 4
3 3
E , E ~ I
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1, 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:
/62
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
5 hi moo
CST SIGNATU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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