Loading...
HomeMy WebLinkAbout020-1136-60-000 a n N O g-0 n d r~ o m f c d o c " ' m (D (D m ~ Ct O i 3 3. F n O N 0 O O W W C O o c 3 c m n N j a z Q m N o f 0o m oo :3 ID C co o a m a o m N o rn t \ co o c Q (D co o o Q N G/ Q O0 O C N ~l co !V o w o w G tD t~ (n D F` Cs m cc N m a UD c m ~ 3 p - N rt m a o o r r• ` c\ N m frt U: H m ~ ~ cn o W W . a cn A fA co ~ r, I o 00 C:) I ~ v v v? lr (D ~O fD ~D ~Q W t7' A O = D z 1-3 w o n vii can a m 3 c) C/] N v v v v° O r rn a o - = m (D N) M N) d CL a a O~ N O z co a O u - z =:h > CD 0 00 o. 00 w 4- CD c m 01) CD (n In H. N ` CD l N (a N r Z v` c m m E b w a CL 3 r• :5~ fD o N o A Z n QQ rt 0 a A Z O p~ p e p' 10 rte{ - ZC -1 ro Fl. ca 'U (D M Fl- C) a, CD CL z w rt o , a rr rn o G 3 m z ~i ca o =O D 0 a c m o -n T CD _ c 3. o o N 0 c s a fi N N C ~ N O p O_ < 0AQ ti C+a '.9 0 O ~ C a O 0 ti Form- STC - 104 ' AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIPS SEC. j T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1I4R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM .~r fd X 3 ~;=I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 1 LI Elevation of vertical reference point: Proposed slope at site: i SEPTIC TANK: Manufacturer: F~F' 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,O Rear, feet 0 --From nearest property line c Front, 0Side, 0Rear, O feet Number of feet from: well , building: (Include this information of the above plot plan)( 2 reference dimensions to SEE REVERSE SIDE . R PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width:_~ Length: Number of Lines: Area Built: Fill depth to top of pipe: 1 Number of feet from nearest property line: Front, 0 Side, O Rear,0 Vt. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 16 kmi pEPARTMEfNIT GF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HOMAN RELAX IONS PRIVATE SEWAGE SYSTEMS DIVISION P.O,BOXj 96,9 BUREAU OF PLUMBING M'ADIS'441' WI 53707 ~p~7I QXCONVENTIONAL ❑ALTERNATIVE State Plan I D Numb- (if assigned) " ❑ Holding Tank ❑ In-Ground Pressure O Mound NAME OF PERMIT HOLDER. (ADDRESS OF PERMIT HOLDER. INSPECTION DATE. Arnold Bertelsen I St. Croix Heights, Hudson, WI „If-~~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST HEF PT. ELEV. NW NW, Section 20, T29N-R19W, Town of Hudson,Lot#67, Willow Rdg.II Na- I I of Plumber. MP/MPRSW No. nty Sanitary Permit Number Richard Hopkins 1059 T St. Croix I 58919-T SEPTIC TANK/HOLDING TANK• MANUFACTURER. LIOUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELF. V.. WARNING LABEL LOCKING COVER P OV DED. PROVIDED-. YES ENO EYES ENO BEDDING: V T CIA VENT MATL r HIGH WATER NUMB R`'OF ROAD: PROPERTYr I J WELL. BUILDING. VENT TO FRESH 11 " ALARM FEET FROM yy ~~I LJ NE. AIR INLET DYES ❑l o ( r ~ EYES NO NEAREST lI t} 1 DOSING CHAMBER: MANUFACTURER. BEDDING LIQUID CAPACI TV PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED EYES ENO EYES ENO DYES ENO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING IVENTTOFHESH (DIFFERENCE BETWEEN FEET FROM LINE PUMP ON AND OFF) EYES ENO NEAREST 10 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing N ,rlt DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO. OF DISTR. PIPE SPACING; COVER INSIDE DIA. -PITS LIQUID BED/TRENCH , f TRENCHES MATERIAL PIT DEPTH DIMENSIONS ) b If r /y GRAVEL DEPTH FILL DEPTH' b TH. PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO DIES R. NUMBER OF PROPERTY WELL. BUILDING: [VENT TO FRESH eELOW PIPFS~ AB.VEjOVER FLEV. INLET ELEV. E <D / PIPES FEET FROM ,LINO 7 AIR INLET ~wf~jji' NEAREST--y- 1 / s7 y 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- meets the criteria for medium sand. TIONS MEASURED. EYES ENO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS EYES ENO OYES ENO DEPTH OVER TRENCRBED DEPTH OVER TRENCH: BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES EYES NO EYES ENO EYES ENO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. JD~STR..PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.ELEVDIAELEVPIPES DA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ENO EYES ENO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: INUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE ❑ YES ❑ NO ❑ YES ❑ NO ,NEARES7 t Sketch System on Retain-in'cQunty file for audit. Reverse Side. SIGNATU - TITLE DILHR SBD 6710 (R. 01/82) r ==wmeMr wlsconsln APPLICATION FOR SANITARY PERMIT ; D 1 L H R I' COUNTY oEPRRTI-1EnT OF (PLB 67) UNIFORM SANITARY PERMIT # In OUSTR4+, LABOR 6 HUTRn RELRTIOFIS 5of V - T -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: VILLAGE: ! 1 /4 1/4, S T--- N, R E (Or) w WN o r LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LA)DMARK STATE PLAN I.D. NUMBER d 1 r ~ t. ~ TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): i' THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. •Ej Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ioo o 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): ~q (,~I Q Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Prin Signature: ! /MPRSW No.: Phone Number: Plum/hers Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber f 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. St^iNf E AR i PERMIT ~ j COUfITY 'Hi TRANSFER/RENEWAL UNIFORM PERMIT (PLB 67-T) PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: (PROPERTY LOCATION: CITY: ~4 VILLAGE: %4,S T N,R E (or) IN TOWN OF: LOT NUMBER: (BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: i PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: I 1FH0 P E P• Uf..FER. IAD~RES= ~ I I, the uncersigned, hereby assume responsibility for.insiallation of the private sewage system that has previously been approved for this procerty. PLUP. ER'S SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGED): / l II J ~j - DISTRfEU`101' co.'1 Su_..3u 04 P!. .,I f I? B. .6 7 P OT PI` OJ ECT PLUM E I~ E/ NAME - NAME LOCAT 10 NJ L_I C ENS E ! \ A T E r ' PL ? f V~~t. Kc ,44.4 s l oa t1 ~ iz~ S 1[ _ 'C ` ~T E 1,5 > f ti,ee 1 SQ f FRESH AI P. INLETS AND OBSERVATION PIPE CROSS SECTION Approved Vent Cap Minimum 12" Above 4" Cast Iron Above Pipe i~ Vent Pipe To Final Grade!--_---- Marsh Hay Or Synthetic Cover-ing Min. 2" Aggrect4atle _ Over Pipe (J `i Distributio Te e Pipc I' Aggregate Perforated Pipe Below LO 1' Beneath Pipe 4---- __Coupling Termi.na ng At Bottom of System - - - - v w P m x ~ x w ` wSCncnn~30 ~mo~ m m g n cr (D N 0 a3 -a ~~w co Q 0, c 0 co co Z E ~0 3m °0°0;' - FD' -0 0. cn cnn to j (D U) CD O ' w ° O O co o a 0 g ' w oo N XC0, W ~ 0-;D ~oN~w R~ -1 =r CD - D ED co CD " O O cD M OD 03a °.-.-.n W O CD c o w o t0 W to O _ C 0 0 l< C- C - 13: 3 c o S-3 0 a 0 O'Z(o c`<QO W w w 1 w w w cn w _ o' m o -0 a C w N CD vim D D c o ~ (Ca cr mwc cn>c=mom !7 w 0 w = ° ac 2 "1 s 06 CD ca o =r Q w cl) ~ 0 Nov, ~D)CD Z D Z N N M o =rtea m nCDo 3-.Nwv n (D C (D ° =-r * t0 n va r.w=r wo w a" 0' W CD =r > CD U) M- a c0 * U CA v a a c n* C IT1 ?mo v, wm v 3 o m_ CD c O a w v, N n i.e 'CD w=~Qw~ _ (h o -o U)0 --cam n (n 0c =c(a~Nai m :0.W)3* CL ccnc0 cawo R1 w w (D (D to a a a CL - -1 0- = CD m.0C L~coa 0vi~0NO 0.0 = o co c -i O C (D m C " 0) CD CL =r W ;z 0 0 =r a c c CD O O M tp 3 pa c 3 O 0 3 co N a o < cn o z NQ o H p f D Co 0 Co n Z m C~ r : C003 w v) ~o ilb, rn ~ cmn C7 co Wis Z = c ~ C7 r C) m D n l 00 m z Z D o C_ -n i \ z C M Z Z Imo. Q O z C/5 m z C O m ° Filw • - Z ~-m m m g m m s 4., m- ! C ~c d ° am am °v C~ r of ma3 3. oa 1 3-' tea, He = ° a o . d v m N D 9 ti < ~ C Q Q< d lD (D ...I F r ,0 3- 3o m s m m 3 ~ ; m o a 70 D m ~ ° Jy > m m am m I m c_ N'~ 3 C m o cc) man o ~ j= 7 N 3 ~ Z , r sm S 3 3 3.a ` o o ~ ~ eo N 1 d m m < a m ~ o Z r H D m a m a o D oa o D < 0o o SM3 m~ ID m m o ° 3 3 C 0 =7 3 dc. oD° to ° N cn D - < m 3 d c D .0 00 o aa . < . a 0 o ~ H , Fr m ma_ 3 f.o'm ♦ a m m m 7 ~7 m. n O E m n d _1 O y f c O 7 0" W 3 .fir O n <D `G (D N fD n C) ~ p] o o 0 of z . :7 3 v o E a iv ° v CL m Z O_ N N CD CD ''..i O `r3 p w = fD O N N j Q) N CD NO 0 C W n O M (~D n O V O W c O o 3 N a O 0 Z L/ A CO 00 Z C { D CL W CD CD (n (n a W a CD (a c a C o- O 3 O rn N m ° ° Z w Q Q N 0 (.0 cc 2: co co C: 0 r (n 01 -P, CL (n 0 Q N1 O !V o Z O O O a'• a o eJ N N ? CT) C) a 0 0. N m (D a C (D CD CL D N ~ 3 ~ N 0- CD Q N Z D Z CD Z Q O (D O O D a ~ m CD v N (D N. c (D CD W a a 7 Z N D -i In O C_ O p Z CD O >I A z O R a C 7 O < N) O co (D < 10 CL 3 z I A Z7 O Z cD m N z m ~ W ~ I CL M a v a ~ o ° T 3 m c Z 0 0 (D O N N CL 0 E a a I ~ I fi N N O O a I A O dQ V O A o 0 ti W a o ~ DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS ti LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P:O..BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 r FK1 CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number ❑ Holding Tank ❑ In-Ground Pressure 1:1 Mound 111 assigned) NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE'. Arnold Bertelson Century 21 Realty,Plaza 94, Hudson, WI BENCH MARK (Permanent reference pool) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT ELEV.. NW NW, Section 20, T29N-R19W, Lot#67,Willow Ridge, Town of Hudson San Name of Plumber. MP/MPRSW No.. =St. itary Permit NumRobert Ulbricht 3307 Croix SEPTIC TANK/HOLDING TANK: MANUFACTURER. I IQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. IWAR1,1111IG LABEL OC NG COVER PROVIDED: f ROVIDED: DYES ONO DYES ONO BEDDING: VENT DIA_. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING. JVENT TO FRESH ALARM. FEET FROM LINE AIR INLET DYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES NO DYES ONO DYES ONO FRESH GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PR INQE PERTV wELL BUILDING I AIR NT INLET (DIFFERENCE BETWEEN FEET FROM L PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA -PITS LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH I(EILSEV TH PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES ABOVE COVER . IN LET ELEV. END PIPES FEET FROM !PROPERTY AIR INLET. NEAREST 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- D YES O meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS _ DEP OYES ONO DYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH 11111 TH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TREONCH ES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. CIA ELEV.. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION ROLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING: FEET FROM LINE. DYES ONO OYES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710 (R. 01/82) wisc~onsin APPLICATION FOR SANITARY PERMIT ~ f ILHR ~ COUNTY vv r~ OE°"gT^ InOUSTq V, ~ . fR OFBOR 6 HUmgn gELRTlOnS (PLB 67) UNIFORM SANITARY PERMIT # ~ l /il 9 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 19L 416-1D L/~ ~k 4 7E 1~ 0 ~ /~ILi ~ ~Pv Z liD~o 4~ 1 PROPERTY LOCATION qq CITY: N1J1/41jk)1/4, S Zd , '1 N, F~T E (or W TOVOw OF: 1 v D ~D,~ LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD,' KE OR ' ^ '^^^AQK STATE LAN I.D. NUMBER 11 l f0 L"J /0,¢s' S' TYPE OF BUILDING OR USE SERVED )k1 or 2 Family Number of Bedrooms. ❑ Public (Specify); THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair L] Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System L~ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. A Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber IV Holding Tank capacity Manufacturer: (,{,Z S C j 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 Feeeej): / Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: PRSW No.: Phone Number: HOMESITE SEPTIC PLUMBING C 3~4 ( N) Plumber's Address: ROBERT ULBRICHT Name of Designer: WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved Ll Owner Given Initial CL Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD ll 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. f APPLICATION FHR SANITARY PERMLT rc - IUO This application form IN to bu completed in full_ and signed by the owner(s) of the property being developed. Any Inaduquaclus will only result in delays of the permit issuance. Should this dove Iopmaic'be Iutaided forresale by owner/contractor,("spec house"), then a second term should hu rrLdined and completed when the property is sold and subml.ttad to Ihi" ofllc.e with thv appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - Owner of Property .____..C-2 //Y/,* Location of Prolerty T N W Township f~1 Mailing Address _ fLr' S `1 ~S . ~ ~D / Subdivision Name fl n/c[ ~ C i L/, Inc Number Previous Owner of Property Total Size of Parcel 3z/C!~e S Date Parcel was Created ~Z2 Z/ ;1 Are all corners and lot lines identiflabl-e? Yes No 1s this property being, developed for rusale (spec house) ? _20- Yes No Volume and Page Number as recorded with the Register of Deeds INCLUDE W LTH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordingd filed with the Register of Deeds Office In addition, a certitiod survey, if avallahlu, would be helpful so as to avoid delays of the reviewing proem;. If the dppd dpacription references to a Certified Survey Map, the the Gurt. I l I rid H"I VPY Map HQ 1 1 "in" he ruqu I red . - - - - - - - - - - - - - - - II't~l'I I' 11' ~i~'IJI I' ~'1 I' I I I I ('AI I ON 11 (lie) LC..n-t(.6y that out A a('I)an(5 ou & 1 Rill (fn i`hu to the beest o6 V (OIVL) knototedge; That ® Intl-1 me (ri.'tt) (it(, owtioh W o6 the plorenty deZeAtibed in WZ6 .in6oAmut,ion,6o~tm, by Wa key Q a w~twi~ti y deed Accorded in the 066ice 06 the County hegl teem o6 Ucek as Onvumvot No. 31;es' p3y~ and ,thaaJO (we) p~te•settt.Pt/ [natt the r~'tuJ~n,1t't{ ~tii(t' hint 01c r~t'ti~trlt" r~M1 rte. ,Sg'tettl.( SIGNATURE (iF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED II r S T C - 105 r r Y H SEPTIC TANK MAINTENANCE AC REEMENT r+ 0 St. Croix County sa 0 y 14, OWNER/H_UYr_I:_- ~ - - R0U"T'E/BOX NUMBER Fire Number C I 'T Y / S T A T E - - ---LIP - f7~ DSO CU /S PROPERTY LOCATION: AW 14, $jto _=4, Section _,zp_, 'T' 'T'own of I LC~-Spy St. Croix County, Subdivision p_ Lot number w ~I G~ 0 P I Improper use and maintenance of your septic system could result ill its premature failure to handle wastes. Proper maintenance con- sists of pumping Out the septic tank every three years Or Sucher, if needed, by a llcense_d septic ta_n_k huIll 1)' WhLlL you put into the system can affect tide function of the .,,I~Lic tank as a treaC- mcut stage In the waste disposal system. St. Croix County residents maty be eligibte to receivu a j;rant for a Maxi.mu_m of 607. Of the cost of replace111unt o1 a failing system, which was in operation prior to July 1, 1978 St. Croix County accepted this program in August of 1980, with the rcquirt,mcnL chat owners of _ill nC_w sy;_tems agree to keep their systems properly maintained The property owner agrees to submit to 5t. Croix CODUty Zoning a certification form, signed by the owner .end by a master pli-ember, journeyman plumber, restricted plumber or it licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank is less than 1_/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x tile-standards set forth, herein, as set by the Wisconsin Depart- v mentof Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DA'T'E -_~L ~ J C St. Ciloix C.)unty Zoning Office P.O. Lox 98 Tlammor d, W1 54015 715-7~ 6-2239 or 715-425-8363 Sign, date and return to above address. a , v r x ~ c ~ ~ -i v~ to N v g ~'mmm c?O n 0 a H o ~3 o~w i m o m C E; D -0 a m 'COD S p :A- m m o o CD CD 0, wpm C<L i_ ~ mom' ~ I $ co m m ~ =r ca w 3 a a° C :Dl m o o m co w =3 =3 ElF c o w o fa w o o = L C C N c o c o• a° cl<a- Mc m o ~ m, m_ ~ w w u, wCD o~oCL CD p' Amc~ n < mo Co . CD mQ c° Q C) c ^ o ° Dw ° o C c - a CAD w o a Q w ocnCl) m ~ In C m m V1 w s w tin f o F D CD D (n CD C- M, CL CD o 3~mCD ?a D --I CD , ° cn (0 to - D 0. =-r MC !z (n CD w CL m C n* a v Imo vai'Nwwm~ C RAY ~m mcE; ~p~m~? ~mm w ° CL m=l p 0 cep D ~ + 0 CD w m n (a m \C 'a3C Nccc w w m M CD CD o RI a^ aaaa ' 0- cn 0' c r `<f~ =r m Imo G7 'c mm 3 o n ma OA m o co a ° N n cmn ' C r po a j o w s o m a w c o S, 3 0 -3 fm' w a' a m ' ° ~3 w m ° < _ `Q o m ~z c ~p G'-PA9^MENT 01: REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,', . C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 969 HUMAN RELATIONS' /t/ . (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: /V 14) ~/4 2-o /T )-9 N/0E (o /,1 U~Sa•✓ 167 &,//~W Pi _4F-7 COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: f = C ~~X OL' I", Ratl s •~1-C ~P4;9/~ 1h~ g 7 ! USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 1 11 / / /L New ❑Replace I 4V U RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: -GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDEDSYSTEM:(optional) $ ❑U 0 S ❑UIM ®S []U ❑ S ®U ❑ S ®U d~vtt3 idv~ 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: rv rT PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) e? 0 • 7 ~c1 ~''J` 'G 6Y, /-5 RA) LS, /.33 D/1 /3,t) C-5 B- Ut.t' Cs ' /T ` , c S; /66,- ' 11.01): `S° ' '%rf A-; . B L S _7 .5 &.44.A cs- . °3 LS, • 67 ~N LS, 7f ' O.P . S w B © 775S )erj-- d' Gee 7 _ ' 7 ,-Iv el ,e ► q,5, 731- r tL3 P,,6.a'J. tS, ,-f'3 40.Gst /.G(, , /,/.QU. B 16,E 70 > s B- PERCOLATION TESTS k- DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES IN AFTERSWELLING INTERVAL-MIN. PERIOD1 PERtOD2 PERIOD3 PERINCH U W E E- S~ Z - aefe:z /n/~ .P cL ` f ,P P- 2- reA7X- 6 4)4 74e 4~ - zt) //0/4- 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. 6770,M 0F geP Y, Ls'~ C// ~ t!', ` /J~ i~ SYSTEM ELEVATION Ae f-1hA VERVCa . /9T 611, li e)A-)~ 77 . E a 3 e oooooA - 3 6'~~ s - - - t N 7 ~ E t L 5 (I I ~ I E [ r x f E I ~ I i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: HOWNSM TLI NC CO. S-2- e- P 3 ADDRESS: RT.3j O•NEIL ROAD CERTIFICATION NUMBER: PHONE NUMBER (optional): ,_,3 = b 1 a- (v 00 GNATURE.- DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - K he a co l o'up ! d ; a"; rrWe sail test, Yom WPM numt Why: 7. TC'. u°,F. Ste? rnt}sf ._:~E'c~i ~ .~_1i€. € £ ,6;?• _ , `Pl._ E=y£t,t ( t~ C;C~3;'t£,tf r=,+:+~ C~"t,7~L"-i;t; ° l" i!A 1(gt.£fyI nurnber of biEd,trf,o!s of L`f1£3'it, tEscfa3 a pl,.A nl-z 2 Is too; a rw r ,?f' rej !U. me Spool; 5. C..;t;r t.Ave ohn ri[, .11d(?:y Mi=i3tiCi;'=.'s- tBASED SITE IS Si"{ 1 t~,1ri.1. FOR O=i r[~v} 31 isK C i F .i,3` , , _ MM: ARE RULED OUT O N SOIL Ce ti i~ ~ A3E ~.144?# S: 6. PLEASE use Roe chart vKH i n sl€ovvi We foi vvriti l.i l>£oir1P: U'esw ipiio stand completing the V1vai plan; rv"sPM<E A LEGIBLE diagram oa-r„i.ately icaxrkg y€ or test 1oCa 0o E;;. Di :vvinq to scale is preferrod, A M{ s we you . = t .tlwk and t' tkyl El, aa3t„ n .i r ;Pme'.€ int am *:Ica. y .ato„ nl and re nla <<'nt; al i: .R,~? 's. }c?j ki . t af t ~.li,, od plain C1e. a, ~1rt£Ct"} t€?__ !st e „!1 1c~,3t :~""a .o Ctei"~€)3'{€3C71p- 1.__ li Us ,_txlr._-a, , a.:n n., fle,-n7~ F .x`3,1, f;lc, `d tl3J3~} € ma nm aYQ, I h ,KA. c.', Am am „a7C(13te Ww; 1 £ qn thn Er,YI"3`t'and ,110c;,° SOU!,.s;'tnl address and ~~.at.£; C,=t fiv~?TECf. ,~tt( „}isr; 12 M. E-.'.j€K {°,{ok and d{:>W1:)t+.e as r€'c:gdre!1. ALL SOIL. t FSTS ,VIUS1- E FILED _ ITI-I THr-. LOCAL AUIHOFUTY AIMN 30 DAYS OF COMPLET101N. 4n dq t :~e syn-tLs~, _ ' i;'~t'.'3 14,1 3 B B orcwk t Ezi3 13 2 un ac5 S n~E. qois`chi - x } F Lownrunu ,4V San""" 3g rs"' _ E< tAEt cFEFn Lei m"ti jM iar ai t LPk £31 Fine MMI 04W sn.Av 1.t <qi°n L "n E 1'636 1 >.4rzf 'f, - 13 m l 11 Loma B~ Black j My Low, r €'i MUM `'z € Y Coy ifs few, law, faW, GO cu CMnMWj nlar--"k, se, 5m w tw- 5 ~ _ j M Q3 .w .M r. LC PLOT PLAM ppoTrr--CT T. D. DA rE- S~~ HOMIESITE TESTING CO. A C57 ;T- o2 moPo5ED "oo5E mosr Lic aj' Fr' o,4 mofs' ~~~~s ~L T , ,{'~'•~}S, PROPOSED WELL MvST L.i~ _ro Fr 6,~ AJOX6` FWOM 1_T-"':7- AfPZ= 5. • = 6Aa-11--0E• Pi7'_3 O = 470571AI6- edELL = ' l©C~¢,7'®O,iJf = ffAtl f~v~EKED CA* 5'4odEL 13ot.F5 4o crA)T'C9 VF ~d PEP u `?v Pius p/ is _ _ - ` SLOPC~ i'o ~Lv~ ys' ~a` 3o SGO~I ' 134/ 6, 'oo l~ , o X ~2- , ~(r 2- 44 3X . ,P .k 1~~~ yJr r ® /d it TO 0 r ,r t i .01 \~a Q7 1 ,V O Y / i2 M Nl 14 z , z ri 7:Z? 0 :e ti - 'Au i t C ~ e e` ` ` 1 3 .aa 14 •~to `-,+/-,mac y ~ A ~ ~n v~~M~ ~ All h1 f v 1 cf 1 : 1 to* 1 .t yb~ ~ i . N. rq F o • 40 Ak- Il 'a ~1 (t It it is tt 1~ 1~ [t Is is ti a\ s' ~ yl T w e A ~s•,~r~r ~ VO '„f +4 rol ~ ` V 3 J ~ J • ~ ~ 7ti y- z = Ufa ,~E~ ~oi~T Tof PLB ~7 . PLOT and CR055 SEcrj o N PIANS v U I1 SEpfiC ly z i + /~soD 0 ~ 1 30 sETy Fr P~Pa 7~6T- S~GNFD `/CE~SGC' -;pr- HQMESITE SEPTIC PLUMBING C0 R_ )'&I n iJ.54U16 ROBERT ULBRICHT WIS. MASTER PLUM6ER !.iC N0. 3307 2 P.R S. nLCER & UL616NER LIC. NO. 00663 04- Fresh Air Inlets And Observation Pipe SOIL TE5T/,05 By MOMESITE TIESTNG l~ Approved Vent Cap RT.3, c:'C•]ej,. Rte ~'3 HUDSON, WIS. 4016 Minimum 12" Above Final Grade ,n /0 M~XIHU/"~ _D 411 Cast Iron Yz " Above Pipe - Vent Pipe i o Final Grade Marsh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 0 Aggregate o Perforated Pipe Below Beneath Pipe o Coupling Terminating At Bottom Of System ,y it 0(aATTFO LANOJ • 0 _ ~~14i //.:v y /.w Sr.Yny~% y /A• -F ..':~Xl.. • ~r,uN a f J~. Crow 4 ~ C ~ ~t k y o i r- iv O J `8- M- Rh I p ; O Y N ° a15 ~ + l ivSrw. 2V = ;to to D u. D D \ ti / ir`" II °p _ ~ 2a \ .l o A i ti ~~"i: JNS~ ~ to ,v~o• ~c w r,rw z: y ~ ~ D y` D R: ~ c .v ? a 4~ Y O c o ~A df4t ~ Z lam 0 z I N, lb 4 f zX ^ I E E \ 4o M ~ p m I"FI 00 ~ X'Yiccew r?ioac Aeo/r/e.v bt ~ ° - _ o i - • .v~cmocn .rs Savnv § 4 ~ ~ / ~ ~V ♦ ° ~1 r s Z - .vo•oS'eo-w ssseo ,m 7~/ k ~q 'tom .0 I w.,+,.rs..n. zo~ _ r \N' o a " o -w--- Iz zy ~ 17l; q ; , F~ ~ i / ~ F Xr 4 ly n m I j I~. II 411 ~ h ;:ry n, 1 a I • c`of'~p40~4`` ~ '~bM r SR ~ft15 k ^o V 8wrfFar 0 W*.Y a ,F - -~.as~ ~j~ r V 41 1 I. c~ O c-c,~ ! ivy" \3}• ur i./~P~ ~'r~2 ``~•~y~i/r~ s', ' o e ~}~'~3 I 8- '09. 5~ L~'aa'~ILi`^•` - o~,ss , Z>~" --4 9 2 cW ~ ~ ~ i L r\~ ..•.B s 5'S 5° ,~a''♦r! ,wz ~y fi 4'y b"4 011 5 I W2 ~~~54/t~ ~ 1'I, ~,r~c~~•Z~4 A~ ~,v e4~1° r t a<'"nE^r~ IO a ^ 5 ~1 ~ q ClB b '•i ~+~/~F 2S `1~ ''i~ Ya ! ~ F i eta i'^'°; ~ 0 clrl + i3;rc^dl'a'F: I s~, . Y/ 'o n ,~J' MO\~°+1+ ~IiofN ~ 8 I. Q yl r' ti VS ° y ` 6' e 4m ; ' n Al to ~ g: - rloo~~,,tc.//1=. yy~, ~ ~~>•.r..o,M a Z ~;a :0 V, tit I . ~lv v~ A \ 1~ II4 M Y•bN „I.' - M'pN gY oq' O I ~~a 2 $ C o r oa.~ 8 w~ 1! I b w~K N C' t" h M e ~S , CLI I;c1~ ,w..,.. r•• 8 'C~,+ ; ~,x Zcf'- b i Y I may 00 1 L.i'' 4 1 O \ t'9a" I "i9°l~ s r1 ♦ ~a.,ssc~ - sr,se•aac 1is,