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HomeMy WebLinkAbout016-1056-30-000 -0 ° 0 3 0 o ° N o o Cl) N L O N ~ I i t3 ~p 3 C 2 o_ a a) .Q fV T N O E 7 Q) M u! L) y O n Z N O a3 C C 7 a) U E LL CO O Q U 'O O N Z Z o z r `m m i C 04 U) O C C7 U O z : c aYUi Z O C O fA F- rn a) z j E Q) Q) j N C N cc ~ a N CL) •N ` U) 0 z co z 0 C M m N C V N - a) O " co 06 LO CL m !v Cl) y a1 O v D a w co L _ a) T (n (n tc ~ w E a v~ 0 'v 3 Z o 0 0 0 M M M N 0 U) O (n J U CA O) Z ZV! O Z7 F- ZN- C> ° = E ~ I 2 ~ N d i N m N Q) O) N 'd cn M d Q (n co M a) R D C O C O b C .w O o~ F o6 a) n C w LL O l w O C m C O N 3 fn N N 'D Z ..CD+ F.y (O LO a) N a~0 p y m O U O Z N 2 H ^L co • O N C7 J co O ~ ,r V d poi ~a #6 a L: o~ ttl~ri 'c c S ~n.~~'l0) ~1 A c0 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P f - BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 c CONVENTIONAL ❑ALTERNATIVE State Plan LD. N-be (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 8405783 NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Selvin Lee 111 Tiffany Cr.Rd.,Glenwood City, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. SE NE, Section 25, T30N-R15W, Town of Glenwood Name of Plumber. MP/MPRSW No. County Sanitary Permit Number_ Gale Smith 5690 St. Croix 58862 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.'. TANK OUTLET ELEV.. WARNING LABEL LOCKI G OVER t { PvROOVIDED. PROM E i C1 ES LINO ESQ LINO VIENT BEDDING: VENT DIA.: VENT MATL. JHIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING_ T FRESH / ALARM FEET FROM LINE ( AIR INLET ❑YES LINO [:]YES LINO NEAREST k __S fir tai DOSING CHAMBER: URER WARNING LABEL LOCKING COVER MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MAE PROVIDED: PROVIDED: ❑YES LINO YES LINO ❑YES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ER OF PROPER jY WELL JBUILDING AIR TOE FRESH (DIFFERENCE BETWEEN FROM LINE PUMP ON AND OFF) ❑YES NO EST D MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing DIAMETER MATERIAL AN FORCE or excavation. (if soil can be rolled into a wire, construction shall cease until MAIN , the soil is dry enough to continue.) CONVENTIONAL SYSTEM: \ WIDTH LENGTN~ NO. OF DISTR. PIPE SPACING COVER INSIUE DIA. st PITS LIQUID WRAC PIT - DEPTH BED/TRENCH l ~ TREN HES MAT DIMENSIONS ( ' I' GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. IPE DISTR. PIPE MATERIAL. J:NO DISNUMBER OF PROPRTY WELLBUILDINGVENT TO FRESH BF LOW PIPES ABOVE COVER EL V LET ELEVND P y FEET LINE AIR INLET._ - •`2 7 ) ) Z f t' NEAREST M-= MOUND SYSTEM: 1 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 LINO ❑YES NO DEPTH OVER TRENCH BED DEPTH UVFR TR ENC H;BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES LINO ❑YES LINO ❑YES LINO 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 VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS. ❑YES LINO ❑YES LINO PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF PROPE RTV ILDING. COMMENTS: LINE FEET FROM ❑ YES LINO ❑ YES LI NO NEAREST _FELL,_ _ Sketch System on , '--Retain in county file for audit. Reverse Side. / SI GN A T URE. - ` TITLE. DILHR SBD 6710 (R. 01/82) - 7 1 Form - S T C - 104 AS BUILT SANITA , YS F' RT OWNER se JZ ee TOWNSH P G GSA p SEC. T„Zo N-R /-,5"W c"' ADDRESS 'MI rjA;o4'i9NY d q 80ST. CROIX d f\ SIN 6;46-1VwD ad SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Lee's FteC tR,6 /00 I~ SAL vl S'ePP/G tAN" Ilk, "y g w r yl t' a INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 1yR6'SRP1,1 2y ~i`;eN~ Ucre,Q Elevation of vertical reference point: /p Q Proposed slope at site: SEPTIC TANK: Manufacturer: M c k Liquid Capacity: J D D O rr-4 L Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side,(D Rear ,0 feet From nearest property line : Front,0 Side,© Rear, O feet Number of feet from: well building: (include this information of the above plot plan)( 2 reference dimensions to septic tank) SEF Rl?Vf?R1-)F S I DI" PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: /Siphon Manufacturer: ump Size Elevation of inlet: Bottom of tank elevation- Pump off switch elevation: Gallons per,ycle: Alarm Manufacturer: Alarm witch Type: Number of feet from nearest property lin Front, 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: .S Length:Z /o Number of Lines: Area Built: Fill depth to top of pipe: 2 Number of feet from nearest property line: Front, 0Side,()ARear, O Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid dept h> Bottom of seepage pit elevation- Area Built: i Has either a drop box O or distribution box O bee~sed on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: i Number of rings used: i Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest roperty ne: Front,- Side, O Rear, O Ft. Number of fe om well: Number of fee-'from b Iding: Number of feeC from nearest roa Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj E77-,scons,n APPLICATION FOR SANITARY PERMIT j- (1.2-1 DILHR (-t"~ COUNTY (PLB 67) UNIFORM SANITARY PERMIT # DEPRRTTT1EnT OF //+r+ ~r +r+ ~r InOUSTRV,LRBOR&HUmRn RELF,TIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY O NER MAILING ADDRESS c/r Le__~ X i PROPERTY LOCATION .9"Pr: SE 1/4IVE1/4,T31J,N,R/SO(or TOWN 07 LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ~ . , . /70 Y 416-5- r-ffJ TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. Public (Specify): ' 7Ylekt' y S' t l : Nt THIS PERMIT IS FOR A: XNew 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. 0 Seepage Bed K 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 I)o G Lift Pump Tank/Siphon Chamber Holding Tank capacity manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ~J 23.2 200 k Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. MPRSW No.: Phon 211 Name of Plumber (Print): I Signature: M e Number: ~ (7ls)~G~-~G~o 'Ee_ U d 3 Plumber's Address: Name of Designer: 1 ~ v u -5 COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 7 6 ❑ Owner Given Initial y Approved Adverse Determination Reason for Disapproval:r 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. PLAN APPROVAL Safety and Buildings Division Bureau of Plumbing DI LHR P.O Box 7%9 ❑ General Plumbing Plans Madison, WI 53707 Private Sewage Plans Telephone: (608)266-3815 OFFICE USE ONLY Plan Identification No. Gallons Per Day ►T►~1~L~f /47-7 1 &q> q CC)C3 a( PRIORITY PLAN REVIEW ONLY Plan Review $ Petition For Modification $ Project Name Project Location - Street No. or Legal Description i Co my L ❑ City ❑ Village Town of: C- r' The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the 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: i This approval will expire two years from to 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 ♦ Z cc: OWS ❑ DPS ❑ H&R & Rec. San. Section _~County 11 Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other Smith - Plum-bing & H _ @CtIZg PHONE (715) 265-4838 - GLENWOOD CITY, WISCONSIN 54013 t t .Y• 1 a. o{ LION - n-t A~ N ~t !3f- 1-0 l " 1 1 { Y ( 1 Smith Plumbing & Heating PHONE (715) 265-4838 r GLENWOOD CITY, WISCONSIN 54013 y . sib i n I ~ JAG C06 SIN R X63 r w + a i w w P1h. = G0 • 1 / 7,8 PROJECT DETAIL DATA SHEET 'DAME OF BUSINESS LEGAL DESCRIPTION 1 T !7 OWNER MAILING ADDRESS ARCH CT, ENGINEER, G 4 / - (PLUMBER)OR PLUMBER OR DESIGNER f`~~'`'~-~ ADDRESS J~ - 4,%Z I TELEPHONE NUMBER 1. Check appropriate building usage(s) and fill in the ir)formation requested opposite each usage listed. Please consult Section H 62.20. Existing building New building ~ Addition ( ) Apartments and condominiums . Number of bedrooms ( ) Assembly hall . . . Seating capacity _ ( ) Bar . . . . Seatinq capacity Bowling of meals served ( ) alley Number of lanes _ ( ) Campground and camping resorts . . . Numher of sewered sites ) With bar Number of unsewered sites ( ) Camps Total number of sites ( ) Day use only Number of persons ( ) Catchbasin ( ) Day and night Number of persons ( ) Church . . . Number • ( ) No kitchen Number of persons Dance hall ( ) With kitchen Number of persons ( ) Dining hall , , , . ' ' • • Number of persons - ( ) Dog kennels ' ' • • Number of meals served daily ( ) Drive-in restaurant . ' ' • • • Number of enclosures • . • . • . . Inside seating capacity ( ) Dump station Car-service Number of car spaces Number of dump stations ~f (,~e Employees ( total of all shifts) Number of employees ( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2k persons per unit Number of units wi pons per unit ( ) Medical and dental office bldgs. N umber of doctors,tnurses,smediccal staff Number of office personnel ( ) Mobile home parks Number of patients ( ) Nursing homes Number of sites _ ( ) Parks . • Number of beds } Restaurant . Number of persons ( ) Toilets ( ) Showers Seating capacity ( ) Dishwasher and/-or disposal? 24-Hour service ( ) Retail store ( ) Schools . . ' ' ' ' ' • • • • Total number of customers ( ) Self service laundry , • . . . . . • Number of classrooms Meals ( ) Showers ( ) Service station Total number of machines • • • . . . Number of cars served daily ( ) Swimming pool bathhouse Number of persons OTHER . . . (Specify) . . . . . e /_7 _ COMPLETE OTHER SIDE Z. Indicate whether the following facilities are present. , Floor drain yes no Number of drains Food waste.grinder yes no Dishwasher yes no Automatic clothes washer yes no Number of clothes washers 3. Septic tank capacity Holding tank capacity Septic or holding tank manufacturer r width of trenches 5 ~ 4. SEEPAGE TRENCHES: total square feet .2-C, C length of trenches d/ C' depth number of trenches SEEPAGE BEDS: total square feet _ width length of bed depth outside diameter SEEPAGE PITS: total square feet depth below inlet total depth from top to bottom of pit FOR DEPARTMENTAL USE ONLY Signatur of person completing form: Address _xzt Zi Telephone Number ~-4-- 4- `ep Date ;z--,~-------- ~ litio n R -~10~15 1 U4. y~T re~P,l,"l y,.t~%r r .A t . DUS RY OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND ! PERCOLATION TESTS (115) MADISON, WI 53707 P.O. BOX 76 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/M_UftL _ Y: LOT NO.:BLK. NO.: SUBDIVISION NAME: 1/4' 1/a /T. . (or) W COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: ( COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE USE ~NO.BEDRMs.: PROFILE DESCRIPTIONS: PERCOLATION TESTS: ❑Residence ❑New ❑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) ❑s❑u ❑s❑u ❑s❑u ❑s❑u ❑s❑u If Percolation Tests are NOT required DESIGN RATE: [Fdplain, y portion of the tested area is in the under s.H63.09(5)(b), indicate: indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i' B f , " J B B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIODS PERIOD2 PERIOD3 PER INCH P_ P- J P- r 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 surf§e elevation at arl borings,id the direction and percent of land slope. 00€ 9 ak u., {GGM i ,-1...dii Ib.€ -hl, ll-a n, i1IAXI(. 01^ s this a n; s c a ;.7 fl- < °r'` I E'iA . `r_°: 1.('_ F~0 O'U' g B A SIE"D ,,i E0 is,,'Sx P E A 'L l af, L~°t ai 4 , kEMio s a ,t ,ui her` o t t-in3j wo it ' d . €mions 3E1= GCF It t,P1y ? )u 7 C3 (l(ra'', s K L.EG 1 Bx _ i€f?tkr 111 ~,'li z ,i it Io okir t , I k€:r.,..oris D. a w i -iq io , if!Erc,i s tiE;ur sze r , iEtt{f _in C„ tec n1 C( ~,irl i .`s r e, IioI it acr„F, F x,-, is < e-1 d plal," BR Bei j S S sl' 1 c. e s - -s,Ft i?l pl.3 t t t, t .-~,P # cT L [i rI,~sT: is t N rl Fiz ire ~ _ j~r•. STATE OF WISCONSIN DILHR DIVISION OF SAFETY 8, UREAU OF PLUMBING BUILDINGS MILHR PRIVATE SEWAGE SYSTEMS B 201 E. Washington Avenue, Rm 141 PLAN APPROVAL APPLICATION P.O. Box 7969, Madison, WI 53707 608-266-3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The back 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 Street & No. or Rural Route Project Location - Street & No. or Legal Description City or Village State Zip City ❑ County Village ❑ OF: Town ❑ Telephone No. (Include area code) Designer Telephone No. (Include area code) Owners Name Telephone No. (Include area code) Street & No. Street & No. City or Village State Zip City or Village State Zip 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. 3d. 5,001 9,000 gallon septic tank - 100.00 4d. 3e. 9,001 15,000 gallon septic tank - 150.00 4e. 3f. Over 15,000 gallon septic tank -250.00 4f. 3g. 500- 1,000 gallon dose chamber - 30.00 4g. 3h. 1,001 - 2,000 gallon dose chamber - 50.00 4h. 3i. 2,001 4,000 gallon dose chamber - 70.00 4i. 3j. 4,001 8,000 gallon dose chamber - 90.00 4j. 3k. 8,001 12,000 gallon dose chamber - 110.00 4k. 31. Over 12, 000 gallon dose chamber - 150.00 41. 3m. 500 - 5,000 gallon holding tank - 30.00 4m. 3n. 5,001 - 10,000 gallon holding tank - 55.00 4n. 3o. Over 10,000 gallon holding tank - 100.00 4o. 3p. Revisions - 20.00 4p. 3q. Groundwater Monitoring Per Lot - 32.00 4q. (other than a proposed subdivision) Subtotal 3r. Priority plan review: walk through) 4r. Submittal of plans in person, 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 DILHR-SBD-6748 (R. 03/84) Effective July 1, 1984 -OVER The following information is required for plan review. An index page or each page of the plans must be signed, sealed and dated by the designer. 5. MOUNDS & IN-GROUND PRESSURE DISTRIBUTION SYSTEMS • 5a. Application for Use of an Alternative System (DILHR-SBD-6413) signed by owner and notarized. 5b. County on-site. 5c. Verification form signed by county (DILHR-SBD-6158). 5d. 115 photocopy. 5e. Plot plan showing lot size and all lateral distances from the system to buildings, wells, watercourses, etc. Show permanent reference points. Direc- tion and percent of slope or two foot contours must be included. Provide system elevation for in-ground pressure, show area for replacement if for new construction. (TWO COPIES). 5f. Plan view of system with observation pipes and permanent lateral markers (TWO COPIES). 5g. System cross section (TWO COPIES). 5h. Pipe lateral layout (TWO COPIES). 51. Construction detail of septic tank if site-constructed, or manufacturer if prefabricated (TWO COPIES). 5j. Dosing Chamber cross section with construction details if site-constructed (TWO COPIES). 5k. Pump or siphon model, performance curve, total dynamic head calculations and minimum dose volume (TWO COPIES). 51. If the site is suitable for a conventional private sewage system, items a and b from this section are not required. 6. CONVENTIONAL PRIVATE SEWAGE SYSTEMS 6a. Photocopy of soil test (115) by CST, including data for replacement system, if new construction. 6b. Project Detail Data Sheet providing all sizing information (TWO COPIES). 6c. Plot plan showing location of septic tank, soil absorption system and replacement area. Indicate lateral distances to any buildings, well, water courses, lot lines, etc. The plot plan must also show the location of permanent horizotional and vertical reference points (benchmark). Also indicate ground slope with 2 foot contours in entire area, extending 25 feet on all sides of initial and replacement systems. (TWO COPIES). 6d. Plan view of soil absorption system showing all dimensions, pipe lengths, spacing, etc. (TWO COPIES). 6e. Cross section of soil absorption system showing system elevation, aggregate, cover material, depths, etc. (TWO COPIES). 6f. Construction detail of septic tank if site- constructed, or manufacturer if prefabricated (TWO COPIES). 6g. Detail of lift pump tank or automatic siphon, tank size, gpm, gallons per cycle, vertical lift, friction loss, etc. (TWO COPIES). 7. HOLDING TANKS 7a. Photocopy of soil test (115) by CST. A full evaluation must be made to eliminate the possibility of any other system being installed. 7b. Agreement document between owner and local unit of government, notarized and recorded in reference to the deed. This agreement must include a statement about the quarterly pumping report. 7c. Plot plan showing location of holding tank with lateral distances to any buildings, well, water service piping, water courses, lot lines, etc. Provide horizontal and vertical reference points. Include all-weather service road within ten feet of the service port. (TWO COPIES). 7d. Holding tank profile showing vent, manhole, alarm and manufacturer if prefabricated. Complete construction details if site-constructed. (TWO COPIES). 7e. Project Detail Data Sheet providing all sizing information (TWO COPIES). This is not required for residential installations where the number of be:- rooms is indicated on the plans. 8. SYSTEMS IN FILL 8a. Systems in fill must include an on-site investigation form (DILHR-SBD-6196), as well as all of the appropriate items listed in sections 6. 9. GROUNDWATER MONITORING 9a. 115 photocopy (TWO COPIES). 9b. Groundwater Monitoring Report (DILHR-SBD-6412) (TWO COPIES). 9c. Verification of data and procedures from county (TWO COPIES). 9d. Precipitation data. 10. PETITION FOR MODIFICATION 10a. Private Sewage Petition for Modification Form (DILHR-SBD-6689). PLAN APPROVAL Safety and Buildings Division L H R Bureau of Plumbing EZ:P.O Box 7969 ❑ General Plumbing Plans Madison, WI 53707 ❑ Private Sewage Plans Telephone: (608)266-3815 /A~ c9 OFFICE USE ONLY r 00; CFi~~, Plan Identification No. 4-05 -7 Gallons Per Da PRIORITY PLAN REVIEW ONLY 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. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the 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 sanitary permit expires. Comments: By: James Sargent Bureau Director If Questions Plans Approved By: Date Approved: Contact ♦ s b.Y cc: ❑ OWS ❑ DPS ❑ H&R & Rec. San. Section ❑ County ❑ Local PI ❑ Facilities Need Analysis Sectic, ❑ UW-SSWMP ❑ Plumber ❑ Department of Agricultlu,( DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other F= N 2 m m m N '"=~(D~ w~cnUlN3O v C N D CD cp n j 7 co CD 0 Na3 .O~ S~W~ C O co O C C N of 7r `<< O 0 =r CD CD O ch CD Cn CD 0 :3 m aC) n N p N O CO _ x CD (D w w N p p cD CD =r > co n 0 o a c o O Cc c0 w r. =r O p O L C N w Z S C ((D O O O- O O p 0 a CD _ 00 N 0 -N V D O• CD CO) a Cl) -cp Q• O~ j, ^ O N O D C (D C/ QJ n O a :3 ~c (D ~-ED(°O~ 0 w 'w ' mo w Cl) 0 v z o N CD CD 0 =r s a CD 0 3 N O N a % CD -4 w = s o c" M O ~c a Q CL ' > 0 CD 0 ID =r m v 3CD° BCD ~o j N c~D N a N ~CO) N ic ..cD p> > =stQN = CD (D CO) 0 0 -co `,b O a (D -s O n Qj G) =a o~ ccn c c d N O m - CL ~ 4 a CL o a _ :3 c _ cD 3 d g ca 0 ~0c oco:3 o CL O a C c° -Cs (1D -I cD C COD O , a 3 C co CD Z 0 N 0 SBD 6678 (R. 08/83) (PIb 100a) (Wis Stats. S. 145.02) z STATE OF WISCONSIN DII_HR Detach And Return Upper 1 DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 141 Any Return Correspondence P.O. BOX 7969 MADISON, WI 53707 8 608-266-3815 Q ~ DATE: PROJECT: r. ~ y, sFP ~El~/E© r~ IO '91984 I ti OFF~~E 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 ll. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed)- E] 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- El 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. SBD 6678 (R. 08/83) (Plb 100a) (Wis Stats. S. 145.02) Detach And Return ~ STATE OF WISCONSIN DILHR Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING Any Return Correspondence 201 E. WASHINGTON AVE. RM 141 P.O. BOX 7969 fMADISON, W153707 Nall! 608-266-3815 DATE: PROJECT: L7 P FG /gal ~V 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 completer ❑ Additional information shall be submitted in duplicate unless by Certified Soil Tester. (1 copy) specifically noted. ❑ Petition For Modification signed by county, owner an ❑ 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 Il. 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 to Exception Status Form by county. (1 copy) ❑ Calculations for total dynamic head and gallons pumped per cycle. III. Private Sewage Systems ❑ Size, length and depth of force main. ❑ Ground slope with 2' contours in entire area of soil absorption ❑ Detail and model of pump or automatic siphon, including system extending 25' minimum on all sides. size, pump curves, drawdown, and average flow rate (GPM). ❑ Location of area suitable for replacement system - provide soil ❑ Cross section of dosing tank showing pump(s) or siphon(s). data. ❑ Construction details of septic, holding or dose tank if site VI. Systems in Fill (Fill must be placed prior to plan submission.) constructed, or tank manufacturer if state approved. ❑ Total area filled (fill to extend 20' beyond edge ❑ Construction details and cross section of soil absorption of trench before side slopes begin.) system. ❑ Depth and type of fill- El Copy of signed onsite report by county or district staff. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON, WI 5370 P.O. BOX HUMAN 7 RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP LOT NO.:BLK. NO.: SUBDIVISION NAME: ~c /a ,?S /T'3o N/RJA(or COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: ,v J 7 USE C rc7 t DAT S OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: ❑Residence ~r "4 ~ku WNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IIWN-F,~ILILI ING TANK: RECOM/ME-fNDED SYSTEM: (optional) LAJ U S U S U D S I! I U S LbJ S U ♦ G l 1 /~i~O rt 'Y i[s G. G If Percolation Tests are NOT required DESIGN RATE: [Ffloodplain, an y portion of the tested area is in the under s.H635)(b), indcaindicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) /z/ C~ 08 S • Sc l el ' B J,6 93.3 Ivo ~e_ s B- o 9-2,s2 /L6 L9 _36 J/ .7 I >2. 3 t~ C B of ~•C~~ Q , 3Q /I 701 c,l i ~-e~s o ' B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PER INCH P- / •0 P 333 /G N / " /0 P- o ~G ^ f 9 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 5ec , t E ` h - E Dl-, te e ~ 70 1. (1 ~9. © T 89-07 ISI a. , 3 a ~Pc'- 8q.'.09 83I1 1 I [ ~ I i , a f F , a 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 OMP ETED ON: ADDRESS: CERTIFI ATIO NUMBER: PHONE NUMBER (optional): CIS T ? CST NPAJ;U RE: ~yU 1-3 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - ¢g {b g 7" 0, e a9,eg .d «a„ Th-. ws;., NPIAX INN Ul tk.fF01 r o k}i dru 3.,. « f v§<§t 7e tick 'I a,st `,~.-ary3 , e _ c , _C s t., o f AS viui eta Ez, U ' " Le(Iff"'t L' p ,,m 1 st i,a Davvin , to v e; 1 ical po ;#s« IE' Chou {fit c ""v, E,rd#?d ,xt"B f) e?,t=,3 .t' aa! ,3c=j a z«"._cfE ~~cixe as to d:!te-" ilafnuE add _.us, ilodjsl~ i f'C'01 .tlf),; tG~~ < t5p_'s r1 .rt"ni r,,J .ti C;d car - , ,,.2 S S'jn 3 Vv;§3 B! 3' Loarl" F x it'C r 144 s C r i ordm to r Parcel 016-1056-30-000 01/22/2007 03:23 PM PAGE 1 OF 1 Alt. Parcel 25.30.15.393C 016 - TOWN OF GLENWOOD 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 RICHARD J JACOBSON O - JACOBSON, RICHARD J 11455 490TH AVE PRESCOTT WI 54021 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 3232 HWY 170 SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 25 T30N R15W 1A IN SE NW COM 100 FT Block/Condo Bldg: E& 70 FT N OF SW COR SE NW, TH E 100 FT, N 435.5 FT, W 100 FT, TH S 435.5 FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) TO POB 25-30N-15W Notes: Parcel History: Date Doc # Vol/Page Type 08/30/2001 655170 1709/149 WD 02/22/2001 639028 1590/319 WD 448100 841/347 LC 2006 SUMMARY Bill Fair Market Value: Assessed with: 165558 42,900 Valuations: Last Changed: 10/06/2003 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 1.000 9,000 25,000 34,000 NO Totals for 2006: General Property 1.000 9,000 25,000 34,000 Woodland 0.000 0 0 Totals for 2005: General Property 1.000 9,000 25,000 34,000 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 0 P3 t7' w m rn rt e, H ~ ((DD p H. cn H rt ri O " m , rh r' d o' p N. w <i 4 w - z CD UI rt 0 C'~ 00 n 0 N W £ H H z (z ~ O r- ~ f rn ~ d ~ I r• ~ W _ N N O 00 I N 4- N _ I 0o H H Cn p O W Cr O 'd ~-fi ( 1 rt O rt O N cl, In