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HomeMy WebLinkAbout192-1054-30-000 o F a N T m # (-D 3 - n n0 o ° 00i0 m ° co °C • N 3 O fD - O C N N Iti Ir: O ~p Z d y -n d OD r~3 Cc CD 03 N N a= O N N CD (D CT i"S -0 0 m ° 0 m 3 I-- W o au 0 o 3 m ~ o H C 14 7'I O~ ° ~ !V D d m cn D ID a A CD N N a x \ 0 ° CD 3 Cl I c rn o N O L m cn N ° Cn ~ ~ cn N 0`000C00w'IC~rcn Cn a cn 'O* Q 00 3 G " • A O N co OJLJ 0 < Z _ ~f r° a) a~ N N N a 0 D 0= Q 9 O O o0 0 C=, 0 rn CD y -0 tD 'm ° o ! a m CD _ N z z z 0 D D o O O :3 o ~i a N 'i co !~1 • i C I VC~1f n 3 o CD cn A z m 0 A z O C 7 D z co CD ~ H CL 3 z O o 3 m H CD C) ° a 0 CD D ° a CD CD M CD °c3° v c C 3 OC N N. O OZ d _ O i CD CD y :3 o CD °o N D COO N 2- C 0'. O~ <'2n t°n w Cl 7 Z °a~ ~ o N o :3 °o v 3 A b CD A H I d0 CT G O °o i Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER f riJ~ TOWNSHIP -rlc1~ SEC. T ~J~ N-R %C> W ADDRESS f, ! ST. CROIX COUNTY, WISCONSIN SUBDIVISION ~LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I i l INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used L, i 07 r'l r'~'ir>/ Elevation of vertical reference point: 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, Rear, feet From nearest property line Front,O Side, Rear, O feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Li uid Capacity: q Manufacturer: pump Size pump Model: %O0 Pump/Siphon Manufacturer: Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Switch Type: Alarm Manufacturer: OSide 0Rear,0 Ft. Number of feet from nearest property line: Front, Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Number of Lines: Y Area Built Width: ,2_ Length:--2t Fill depth to top of pipe: O Side, o Rear,O 9t fL~ Number of feet from nearest property line: Front, Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Number of pit Diameter: Size: Bottom of seepage pit elevation: Liquid depth: Area Built: =o ibuti `begin used on any of the above soil Has either a drop box or distr O absorbtion sytems? (Check one). w HOLDING TANK Capacity: Manufacturer: Number of rings used: Elevatio of bottom of tank: J-- Elevation of inlet: Rear, 0Ft. ~Frot-t,~~ Side, 0 Number of feet from nearest property::' rye: ( 1 j * of feet fr we l: Number ff Number of feet from t5uilding'/ Number of feet from nearest road: Alarm Manufacturer: Inspector: f ` Plumber on Dated : License Number: 3/84:mj Wisconsin APPLICATION FOR SANITARY PERMIT ®1 L H R cQc'ex - OEPggTTT7EnTOF (PLB 67) COUNTY inOUSTPY, oasHUmanaeLanons UNIFORM SANITARY PERMIT # -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PRO,~P""E'~R I CPO OWNER W G ADDRESS ol/✓/ Ile- Ind ~e L C MAILIN Foq AMU k' TR v.v a 61je o Q/ y (,j/ S 5'10 L PROPERTY LOCATION / CITY: Nw 1/45401/4, S To~N, R /(Of (Or W vIL OWN OF Jig u Ile- LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ~/y ~ NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 11 1 or 2 Family Number of Bedrooms. X Public (Specify): Te THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement Replacement Soil Absorption System ❑ Repair ❑ Revision ❑Priv p~ Alternate System ❑ Reconnection y ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed ❑ Seepage Trench System-In-Fill ❑ Seepage Pit ❑ Holding Tank ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy U Existing, For Which A Previous Permit Is On File, Permit # ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions, issued 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 #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Z.. S"d X Lift Pump/Siphon Chamber X QX / S /wi O Ay Manufacturer: 000 X X OIV .0 10 _L PERCOLATION RATE ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROABSORPTION AEA WATER SUPPLY: POSED ( qua eR Feet): 340 ~?8 .0 191fPrivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for ins al ation of the private sewage system shown on the attached plans. Name of Plumber (Print): ignat e I Alf j MP/MPRSW No.: Phone Number: vc°.e C'4 f- o L ~f -{J7 Plumb ,dress: P s~,Llly9 (7/$' )6,*V3.f 7R Name of Desi ner: ALd wi..~ ~'f S A.»~ . COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: 7 ,~J ❑ Disapproved V + LLf s Owner Given Initial Reason for Disapproval: Approved Adverse Determination 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. State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION All 8 t3isru,41 of P.O. box u b ~L a,4 . ~ r . of Eau Ga wI - :roix i s Variance F i icaticn; ti 63. It; { ri'ot' ranted to alto= instaiidt ion chid Ilse of a brficirig tasik on a te.-aporay-,. i s i s x no to exce~n' E twatos tip ap y y ' t'~ V pti:r „x£`3.17' St~.t~$lt ?l+~~a<:~; -.!,k S v fi _ ns an appropriate fee gust rte: sut i 4 . - . i x: , i• to x'. of :.c Ue ;jepartment for is approv stye 6(-~40911 and, size A Sys=.u f s variance is subject to t€te a{= $ ~-at anv S<#.c4 f,- cottcerttea v for itit s i+iivin ut;forc nt of ivcai ordi€tames per*;. t t irtstd4 atzo i as pr, a` { .e shall /'+li ri e- y g} 'g * all Ml lkr it !Ti it!ir aYi ik tYt t i v>r i i jr vo it j 4 hA s <evaA or an uther• operational c>r adintenance pro-A s>occ"r-, the Svisioos necestary to resoly-e tnest r DILHR-SBD-6423 (N. 04/81) { State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION C"- s:G s W ! icfa ; a }t`C:IF 3Lc..id?t3 oFpfirs kt~ D / ~ yr y~ p~ q y >r l`Jsi'a'a25 , .PFi(.dtiv' cr..~~4"t?sijg-d tY -r any ..IfLF#.qe todt ma rt: t t 1 i to (r: a413t r► s :z v s the rf gift to orUier C~1~4t;`' , s cr '7 Ir i inra~ c;s z11 the ,v rt cunstructiGn *ias not ct5 nct-d with? ifs r~pprovaI wall 'a:.C "art= ► r ttC -f R EW : . +23 (N. 04/81) Plb le0a 12/7t Detach And Return Upper State of Wisconsin Portion Of This Form With - I OF HEALTH DIV Any Return Corresponde , q I SECCTTIOON N OF PLUMBING AND FIRE PROTECTION SYSTEMS MAIL ADDRESS: P.O. BOX 309 \ MADISON, WISCONSIN 53701 608-266-3815 DATE: PROJECT: - 10t~1;G ofrICE 4' `r rage Variu v; PLAN ID. # DETACH HERE 'ROJECT NAME PLAN ID. # his is to acknowledge receipt of your plans and specifications for the above-indicated project. fliminary review indicates the plan review fee required is $ ❑ Plan accepted for review. Fee received is $ =ee is being returned because of ❑ Overpayment ❑ 'roviding one of the two catagories above is checked, remit correct dfeean onetpayment. No fee has been remitted. Plans submitted with no fees will be held in abeyance. Plans being returned. %dditional information required. SEE BELOW. In Submission :1 Additional information shall be submitted in triplicate unless specifically noted. :1 Plans not clear, legible or permanent. -]All information submitted shall be signed, sealed or stamped in accord with Section H 62.25(2) (a) Wisconsin Administrative Code. ❑ Affidavit enclosed. :ernate sewage Disposal Systems (Mound Systems) :1 PLB 108 (Application for use of an alternate system). County onsite required (1 copy). ❑ Design calculations for pressurized distribution ❑ Cross section of mound. ❑ Pipe lateral layout. ❑ Plan view of alternate. Private Sewage Disposal Systems ❑ Ground slope with 2' contours in entire area of soil absorption system extending 25' on all sides. ❑ Elevation of permanent reference point (benchmark). ❑ Location of area suitable for replacement system - provide soil test data. ❑ Plot plan showing lot size and all lateral distances from sewage disposal system or holding tank to bldgs, lot lines, well, watercourse etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. ❑ Construction detail and cross-section of soil absorption system. ❑Soil boring and percolation test on EH 115 completed by certifiedsoil tester (1 copy). ❑ Complete data relative to anticipated use of bldg. ❑ 3 copies of PLB 60 enclosed. ❑ Deed restriction required (1 copy). IV. Holding Tanks ❑ Profile of holding tank. ❑ Holding tank agreement signed by owner and local unit of government (sample enclosed). ❑ Reason for installing holding tank soil test or statement from county (1 copy). V. Lift Pump ❑ Calculations for total lift pump discharge, head and gallons pumped per cycle. ❑Size, length & depth of force main. ❑ Detail & model of pump or automatic siphons including size, pump curves, drawdown and ave! age fiov rate GPM. ❑ Cross section of lift pump tank showing pump(s) or siphon(s). VI. Systems In Fill (Fill must be placed prior to plan submission) ❑ Total area filled (fill to extend 20' beyond edge of trench before side slope begird). ❑ Depth and type of fill. ❑ Copy of onsite report by county or district plumbing supervisor. ❑ Length of time fill has been in place. AL DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION C LABOR AND PERCOLATION TESTS (115) BOX 79 HUMAN RELATIONS P.O. OX 7969 MADISON, WI 53707 OCATION - S A ION - LOT ------NO-- - N fOWNSIIIP/MtJNI( IPALITY BLK. NO.: SUBD\~ O NAME _my'/ j~_Y_'4 1 /T20 NA6 E (or(W f!u Gallu COON f Y - OINNER'S78UYFH'S NANI[~ MAILING ADDRESS: St. Croix Funk Trunk4l (6Joodvilla Mat 1) Rtt 1, Woodville. YJi usE___ DATES OBSERVATIONS MADE NO. 6E(]RMS COMMCIt~IAI_. DESCRIPTION: F~ FTEr-un-cp]p`Pl- NS: i~ N FATS: ~Residtnce Motasil New 2 Ju1y Replace ~,,1981 - - 1 cRc `f /3/61 f; RATING. S-- Site suitable for system U= Site unsuitable for system t'oNVFNI Ir NAI MOUND ~1 IN-GROUNDPHES:;URE SYSTFM-IN FlI FLHOLDING TANK: RECOMMENDED SYS\M:(opt ofidl . Ln S C__1U -_LJ_s_Flu I.. 0 s L_..1u_1 L] S lJu s ❑u Mound If I'eicul,uun Isis air,, NOT reyuuud DESIGN RATE SYSTEM C LFV. If any portion of the lot is in the under s Ht; 1.091h)(b), indicate: _ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BU TOTAL 1' H TO Gf OIJ NDWATFR INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMB13EE l=R nEl'(H IN. ELEVATION OBSERVED ES I HES _ TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B_1 72 96, 9" 6o" 30" 6" to 6" gy ail 60" Br al Mot at 30" B-2 __72 941 8" 60" 30" 4" to 1211 Br ail 561, Br acs Mot at 30" B-3 72 961 211 60" 26" 4" to 102 Gy ail 18" gr 40" Gy c Mot at 261, B- 4--- _72" 941 8" 6o" _ 26" 4" is 12" Gy all 10" Be 46" Gy c Mot at 26" B- B- _ PERCOLATION TESTS Tf T U1 PTE{ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES NUMB 1t INCHES AFTER SWELLING INTERVAL-MIN. - RATE MINUTES BE r310D i _ p -BlOD 2 RT~D PER INCH P- 1 22 no 0 1 118 1 16 1 1/8 26.66 P_ 2 22 _ no 1 1 1 0 P._ ?2 R O 2 2 3 P _ PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suite R~~f-~. Tiua cal zontal and vertical elevation reference Alitrs• Describe wh~i.. points and show their location on the plot plan. Sn~LKSVCtVtWU&0* t~ or~r~larySy of land slog. SYSTEM ELEVATION . ° i I C ~G RG / I I E C ~j' ~ ; I I I ~ ? ~ r Jrs I I I_ i I~t l p C I 1 I T 7 t I I f ' 1 I ► , ? , , 0 i ;4 Ile Aar 7 I, the undersigned, hereby pertify the the soil tests rupDrted on this form were made by me in accord with the procedures methods specified in the Wisconsin Adrnimistrative Code, and tf at the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAMEE (print): - TESTS WERE COMPLETED ON: Stfaphen L. Aaby 7/ j/61 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): Box 254, Woodville. Wi 1ito6 69d--'407 CST SIG AT L - DISTRIBUTION: Original-L'tcal Authority, 2nd pa4e-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SSU 6395 (N. 03/81) PAGE --I-_ OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VEUT CAP H"C.I. VEUT PIPE WILATHER PROOF APPROVED LOCKING 25 FROM DOOR, JUWCTIOKI BOX MANHOLE COVER WINDOW OR FRESH I2°Mlll. Ai:. IfJ AKE I GRADE I y.. MIN. ` 411 CONDUIT INLET PROVIDE AIRTIGHT SEAL I I I III APPROVED JOINT A APPROVED JOIAITS W/C.I. PIPE I I I W/C.I. PIPE EXTENDING 3' I III EXTENDING 3' ONTO SOLID SOIL ALAR s v I I I ONTO SOLID SOIL F.: i U yY~ I I INDU` ` O I I ON L I ELEV. FT PUMP-~ __J ~ OFF D e , ~LRECOMCTE BLOCK RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROAljk SEPTIC f SPECIFICATIONS DOSE TAWKS MANUFACTURER: e-1.5 A5, ~on/CRe7~~ UMBER OF DOSES: PER DA'.l TANK SIZE: GALLOUS DOSE VOLUME p ALARM MANUFACTURER: A~ m k-, INCLUDING BACK ~O : 6 L2qoNS MODEL 1JUM6ER: (UVo - / ~~~~jjp~-,, CAPACITIES: A= ~ INCHES OR 14~~ GALLONS SWITCH TYPE: m e/Q L ~Y J1/l±✓t' 5= - INCHES OR GALLONS PUMP MAULIFACTURER: om R/ G C= /(O' IES OR 4 CALLOUS MODEL NUMBER: 5/ - /4 0 D = ~AICHES OR GALLOWS SWITCH TYPE: me-le-e-OR NOTE: PUMP AND ALARM ARE TO bE MINIMUM DISCHARGE RATE 7SGpm INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEU PUMP OFF AND DISTRIBUTION PIPE.. U;O FEET + MIIJIMLIM NETWORK SUPPLY PRESSURE . . . . , . , 2.5 FEET -F• v_L rr_ FEET OF FORCE MAIN X /o° ~ F " FT.FKICTIOU FACTOR.. 310 FEET TOTAL 09MAMIG HEAD = = FEET INTERNAL DIM IONS OF TA1JK: LENGTH / ;WIDTH ;LIQUID DEPTH 7$ 51GtL1ED: LICEUSE NUMBER: M P 4q-g(7 -/4 - ~ DATE: P.~ 3 24 wo C' Ile- M'0 e- 20 Wood V1 S Q 16 SV4 Wood 12 8 O 4 0 16 32 48 64 80 96 112 SOLIDS U.S. GALLONS PER MINUTE Head-Capacity: SV40 and SVK50 Submersible Residential Sump Pumps Max. Solids SV40,11/2" & SVK50, 2" Spheres; 4 Pole, 60 Hz HANDLING 32 SUBMERSIBLE ~ 26 24 SEWA =20, _ GE 16 = S~~A &12 EFFLU ENT RUMPS 4 0 20 40 60 80 100 120 140 160 U.S. GALLONS PER MINUTE Head-Capacity: SP40A and SP50A Submersible Sump Pumps Max. Solids SP40A,11/4" & SP50A,1Spheres; 115 Volts, 60 Hz., 1750 RPM 40 28 3 24 K~S 20 18 12 8 4 0 20 40 e0 e0 100 12D 140 te0 U.S. GALL+OW PER UNI C _ g N081142pacity: SK60, SK75 and SK100 Submarak Sewsp Pumps Max. Solids 2" Sphere, 1750 RPM HY0Rw0*M C PUMPs A Division of Wylain, Inc. Post Office Box 327, 418/289 3042 1~-02 Claremont 6 Baney Roads, Ashland, Ohio 44806 j.._._.__~. - In C-dc WVWn CWI Ltd, LAM., TSa tar Cr, &&mM", onhrto LOT,= • W o O CIV al e. /Yh 0+ e. Page Of ~ w000 v 11"e_ 1.11 i S Perforated Pipe Detail PeRF.ero'Fed End View End Cap i I J O\g~o Holes Located On Bottom, S Are Equally Spaced P S PVC Force Main w P ,7 / PVC Manifold Pipe Distribution Alternate Position of Pipe Force Main Lost Hole Should Be Next To End Cop End Cap Distribution Pipe Layout P 4th Ft. DEQA' R 18 F- 1E. S tNG9eS X iInches -----r, J Y _ZA Inches Signed: Hole Diameter SAL Inch Lateral Inch(es) License Number: M P IL yC ~9 Manifold 3 Inches Date: 0-- F V Force Main Inches # of holes/pipe Invert Elevation of Laterals 97.9 Ft. I DEPARTMENT OF INDUSTRY, L4N PECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGESYSTEMS DIVISION BUREAU OF PLUMBING MADISON, WI 53707 ❑CONVENTIONAL MALTERNATIVE State Plan F.D. Nu-'ber M Mound assigned) ❑ Holding Tank ❑ In-Ground Pressure MMound 84-01627 NAME OF PERMIT HOLDER . ADDRESS OF PERMIT HOLDER: INSPECTION DATE. GlvvdviP 2e Mvet-Vnavifz Tnuv~Fze2 (Uvvdve, DUI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.: NW Sw Section 1 T2 8N-R 16 W, Town o j Eau. GaUe Name of Plumber. MP/MPRSW No. Co-, Sanitary Permit Number. EvvLette Botdt 4489 St. cAoix 58875 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED - ❑YES ❑NO ❑YES ❑NO BEDDING. VEN DI VEN TL_ HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH ALARM FEET FROM rJ~~ LIN ]VENT INLET ❑YES ❑NO ❑YES ❑NO NEAREST ,~•C U J I DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROW DED PROVIDED ❑YES NO -©0 0 d""'_ ~CJYES ❑NO LAYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN 1 FEET FROM LINE y I AIR INLET' PUMP ON AND OFF) e/ 41 YES ❑NO NEAREST 70 /G7~ n" - SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NGni DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE 0z _ the soil is dry enough to continue.) MAIN yc CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO DIMENSIONS OF DISTR PIPE SPACING COVER INSIDE DIA =PITS LIQUID TRENCHES. MATERIAL PIT DEPTH GRAVEL DEPTH FILL DEPTH OISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. O. DISTR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH B E LOW PIPES ABOVE COVER ELEV. INLET N ELEV. END I 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- YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PERMANENT MARK IRS. OBSERVATION WELLS ®YES ❑NO RIYES -]NO DEPTH OVER TRENT H'BED DEPTH OVER TRENCHlBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. / O ` ❑YES NO YES ❑NO XYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS / TRENCHES ~ ~ l s MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ~v7(~; C ELev DIA ELE G PIPES Dla O DISTRIBUTION 7~ INFORMATION ROLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED 7f PLANS YES ❑NO YES ❑NO COMMENTS: PERMANENT MAHKEH50, OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LIN~E/ RYES ❑NO YES ❑NO NEAREST 1 ~~v 'SCI Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. IT IT;E~ /~Gt DILHR SBD 6710 (R. 01/82) i ~J ~ o o F - > o c cn 4? O c E o OdaO oo-- om~o E c cot+-L v c o c; s ai o v rno c ov O d 4) 0 m 0 c cm m E m. cC7 o ~t£ 3 ca ` o C vi C73~ 0 0 = p cu cd 3 > > a E c V O cc 0 CM 0 L- 0 Cd O c l0 cm v L) _y - V1 m V m L N O m y c cc cc t c m c~ a o f oD Cd Cc a LU P (D (D N 3 a3 0 0 I- ~cccLi~m mm~ cc p L O L ' ' Co w UJ c o t m N ..o ~w.o Z 3 cf'c-~O0- mac 0 3: tv V) = m m'. m Co m c ie cNOcma~c 0° 3:.0 . t=CD V V 9= L U " ` t m• O Q o V O y ''0 N Q C Q CaL m L wrn-- cn~c c 4? C o r' O CD i 0 co ca c3cm , Cccc coy'v 0E5o cm M0 r- a ooE O O c t C13 ~o«,c o O to o 0 O c c o`~o m m o 0 o v E u rn M C (D L 4) 4-- L- cD c v(0'a0ai 4)CLca Go 0 CC Y O CV 3 0 m c m"O L 0O r o a 3 Vl ) - to N d a Q r c 0 0® C a CD ~ O e Y Q1 rn E w Z ti tV CC M O O O ms o, o x cctt c- a E f~ c o>," o c o 3 C~-r O E N ai can 3 c W Q w x y _J 0 PLAN APPROVAL Safety and Buildings Division Bureau of Plumbing D I LHR P.O Box 7969 El General Plumbing PI Madison, WI 53707 ❑ Private Sewage PI Telephone: (608)266-3815 0 i o ~r jsl 80 OFFICE USE ONLY y/yy 4 f; Plan Identification No. Oki; E 1 T 7 y? U 4- -T I ra , Gallons Per Day - - - - S.T.W. PRIORITY PLAN REVIEW ONIV Plan Review Petition For Modification Project Name Project Location - Street No. or Legal Description County ❑ City ❑ Village ❑ Town of: The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. T is apFroval 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 requirec by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan approval must be obtained. ❑ FOR PRIVATE SEWAGE PLANS: This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial anitary permit expires. Comments: By: James Sargent Bureau Director If Questions Plans Approved By: Date Approved: Contact cc: ❑ OWS ❑ DPS ❑ H&R & Rec. San. Section ❑ County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other Ll.~47 CPg4 'V i Ile, Page L ofS Straw, Marsh Hay, Or Synthetic Covering Medium Sand Distribution Pipe Topsoil H - G F 3 E I~ D % Slope Bed Of 22 %2 Force Main Plowed , Aggregate From Pump Layer :JF INS D /,0 Ft. - oss Section Of, A Mound System Using E :2,::4: Ft. A Bed For The Absorption Area F .75 Ft. G , O Ft. Signed: A cQ 0 Ft. H F•:. Qt,[ Ft: . License Number: B /J)h K O, 35"Ft . t Date:- L ~7Ft. J 7 7~ Ft. Alternate Position of 12. z I. Ft. Force Main 3q,q ~ W Ft. _ L 8 Observation Pipe F W (o - - - - - - i J-- Force Main Distribution B- i i ed Of 2 2 z Pipe I Aggregate Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area t: 3 4 1 ,1 r Zk: t ~ a 4 3 ~r~ or - m cy~ Pl Q'j t3 T 4 APR, \0 i'j r c j Ilk v ~ O a H rte-. H y ST C- 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d 9 OWNER/BUYER /Roxjke- 4. ROUTE/ BOX NUMBER Fire Number CITY/STATE (ipog~i/~~, W~ S 'LIP 5 /0-.1-~ PROPERTY LOCATION: N W '-6, 5W ~4, section T ,~A0 N, R/(-> W, Town of )Au 4lie. St. Croix County, Subdivision /r A- 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 punier. 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. - yo I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- rv 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 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 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording,. - - - - - - - - - . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property /-,?A.j Location of Property 61W ~4 .mow , Section T A 0' N - R W Township Ir- A 0 A Ile- Mailing Address WpoC/V//A. cam/ S Subdivision Name Ate/ P~ Lot Number Previous Owner of Property Le Total Size of Parcel Date Parcel was Created Q C i-s 7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes X No Z Volume and Page Number a 4•.4o as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. 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) eetti.6y that aU statements on this botm cute tAue to .the b+,t 06 my (UUA) hnowxedge; that I (we) am (ate) the owner (s) o6 the ptopeAty dactibed in this in6otmat%on 6oam, by virtue o6 a wattanty deed aeeotded in the 066ice o6 the County Regi~s-teA o6 Deeds as Document No. ~ 4- , 7 P ~4 and that I (tie, ptesent-ty own the paoposed site boa the sewage d Fora, system (on I (we) have obtained an easement, to tun with the above desn bed ptopetty, boa the eon t ueti.on o6 said system, and -the same has been duty teeotded in the 0664-ce o6 the County Re.gis-tet o6 Deeds, as Document No. ) . SIGNATURE OF OWNER SIGNATURE F CO-OWNER ( F APPLICABLE) Z~ / ~ k'~- & - /0 - DATE SIGNED DATE SIGNED Nil ` ~r lL o o cl .10 ` ter, n t L i w a- 3 ~1J IV. t ..M Ai Y~.~'4L u• Q ° a APR ! chi ! ~ ~C ' n ~ `J e N 0 `Q a ~ 3 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.BOX7969 MADISON, WI 53707 8 608-266-3815 DATE: PROJECT: F Ip~g Ig~ ~._M . _ . f F Fatk 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 cnsite 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 fo 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. ❑ T6tal 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.