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HomeMy WebLinkAbout020-1150-10-000 rl . o to 0 F. - o C7 1 0 CD 'a CD A7 n 0 0 0 0 3 a a o C k• _ N N CD 7 n d CD W C)- N O d d (D (D N co (Q j h c ^ m W m m m 03 o O 1 N N a 0 N W O p 0 0 m o O (D :E O O Q m N C (D O 7 O 7r d d S O O 'Y 7 N O O C N ~ ~ !r co (n z D (D a m cn D 'n a ~ "4 ~ W CD N N O CY) O W 0 0 O N O Cl) Z co O O 00 A N N O C CD D c~ Cn x r 0 0 0~ • ~ p D3 It f1 O OC rt N~ N i o. 0 0 0 0 (p rt''`' 'E td o N CL H r"1 J'~ a- W _ cn < F' - N p x .d H-f- o o r z z z a E ON p1:. O D D; a) 00 i.\ rt O cD G (D uN, c~ rt N O v f1' r W O C H C!J O n I tv o W CB ° O d Z m o -i <n f`, o p Z (D 00.1 m o ~6 ~ z o v n A O F! O N i Lo .1 z f- ° 01% 4~1 Iv O C=i = Z N w ~,o G m -0 m Z z ~j Cn m 3 t I rt C=i z 7 rt V o r. a o cn M (0 T~ ~ Fl n m z (D a rt (D H p H OC"l O C ~ N W Q rh 0~4 c rr m r ~ G O o a R co N j N p a a z I ~ N N N O q:l a A O CD bA tv 0 ~0 0 a CD Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~f&V A'0'95- CQ,U S •f TOWNSHIP Lt) 10161A) SEC.3 3 T Z l N-R ~ I W ADDRESS 715 M~~S~ tI ST. CROIX COUNTY, WISCONSIN #6) o - ~T~l7So~ SUBDIVISION LOT 2,3 LOT SIZE 7 fi 'S ~illfl-~ PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM well • , ~o S ~~DM D/~ Fi EGl~ ~tA ~ 'o l o' ~ l 1 o - A 14 ti 10 Rir r INDICATE NORTH ARROW p#6Af- 7?~ L 291-(, . fl• Ta~ ~~Q - /D D. TAP ~ ~Ly z- ~ . BENCHMAV : Describe the vertical reference point used W Z6 r C6kVt p r Elevation of vertical reference point: /00-0 Proposed slope at site: ~o SEPTIC T,;'NK: Mi<nufacturer: Liquid Capacity: Numb(r of r.ngs used: 13 Tank manhole cover elevation: Tank Inlet Llevation: Tank Outlet Elevation: Number of feet from nearest Road: Front, x o Side 10 Rear, o l ~ feet i From nearest property line Front,O Side,O Rear, O > 5 D feet r Numb ,x of feet from: well building: z 0 r (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE i PUMP CHAMBER " Manufacturer: Liquid Capaci Pump Model: Pump/Siphon Ma acturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevati llons per cycle: Alarm Manufactu Alarm Switc pe: Number o eet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORBTION SYSTEM Bed: Trench: 133 _ fS y- 3S Width: ~C3 Length: Number of Lines: 3 Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, © Rear,O Ft 90 , Number of feet from well: Number of feet from building: 3o , (Include distances on plot plan). SEEPAGE PIT Size: mber of pits: Diameter: Liquid depth: ottom e age 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 bott tank: Elevation o . let: 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 • R1 2 HOMESiTE SEPTIC PL limww . R08ERT l►DSON, MS. 54016 WIS. MASTER PLt1MBERULBR~HT MINN. INSTALLER & DESIGNEIR~LI3307 Cr.R^S. . 110. 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ~ ` CONVENTIONAL ❑ALTERNATIVE SPlan l.D. Number XR III assigned) t~ ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME F PERMIT HOLDEADDRESS OF PERMIT HOLDER: INSPECTION DATE. Lungren Brothers Constructio 715 Michaelson, N. Hudson, Wl 54016 -/8'o 0-a BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: ICST1111 PT. ELEV.. NE SE, Sec. 33, T29N-R19W, Lot #23,Countryside Vill., Town of Hudson Name of Plumber. MP/MPRSW No. County. Sanrtary Permit Number. Robert Ulbricht 3307 St. Croix 49438 SEPTIC TANK/HOLDING TANK: MANUFACTURER. ^ LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER _ PROVIDED PROVID jb2,~~ ❑YES ❑NO ❑YED ES ❑NO BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH ALARM. FEET FROM 11 LIN AIR INLET a ❑YES ❑NO ` ` ❑S'ES NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING'. ILIOUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO IRISH GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I AVIER N ITNTLOET (DIFFERENCE BETWEEN FEET FROM LINE PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing It EN(ITIIJ DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. JLINGT TTR .OF DISTR. PIPE SPACING; COVER JINSIDE DIA. SPITS JLIQUID BED/TRENCH p , EN CHES ERIAL: PIT DEPTH DIMENSIONS I GRAVEL DEPTH FILL DEPTH DISTH PIPE DIST. IP DISTR. PIPE MATERIAL: NO. D STR NUMBER OF PROPERTY jE LB ILDING: VENT LE FRESH BF LOW PPESABOVE COVER )S INLET E LFVR EPNDE . PIP s FEET FROM AIR INLETq ILIV NEAREST--s- I j J MOUND SYSTEM: Ty' 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. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS [076SERVAYT IO N WELLS ❑YES O ES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH: BED DEPTH OF TOPSOIL SODDED SEE D MULCHED CENTER EDGES YES ❑NO YES- ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF LATERAL SPACING: GRAY 'DEPTH LOW F FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE IMANIF LD MATERIAL. IND DISTR. DISTR. PIPE DIS[HIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA. ELEV. PIPES DIA.: ELEVATION AND DISTRIBU7 ION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LROE ERTV WELL: BUILDING: FEET FROM i +1 ❑YES ❑NO [:]YES ❑NO NEAREST _ 102 , 1 J jp zl~oo• i7~ `-A Sketch System on Retain in county file for audit. Reverse Side. 1 ' nTLE SIGNATURE l 82) DILHR SBD 6710 IR. 01/ T-=-~- r wlsconsln ' APPLICATION FOR SANITARY PERMIT DILH R COUNTY (PLB 67) OEPRRTI'T IEFIT OF UNIFORM SANITARY PERMIT # In DUSTRV, LRBOR 6 HUMRn RELRTIOnS -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 OWNER MAILING ADDRESS GU PROPERTY LOCATION CITY: NF 1/411, 1/4, S 1 , T." 1, N, R } 7` E (o0 V TOWN OF: ~I LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED k 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): 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. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity r,1 Manufacturer: t-Ci/4 r: x" t ± 4 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): ~h ❑ Private Joint ❑ Public f, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature-~~ MP/MPRSW No.: Phone Number b a " . r . _ 33~7,M~ ("1/ Plumber's Address: Name of Designer: cis) ti f,C 1X COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: k ❑ 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 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. for, Form - S T C 100 5 Owner of Property C2 x Locution of Property Nab aj45:~Z, Section k-'"50'r09N R_/_2W Townehlp h~U~~.sO/c/ Ma111ng Address VV/CS7 Subdivision Name CQUjy ~//L Lot Number Y Previous Owner of Property. Total Size of Parcel Date Parcel Was Created aGTQ'~~ ~9~7 Are all corners identifiable? Yes No Include with this application one of the following,: .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION I I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No 3D and that I (we) presently own the proposed site for the sewage disposal system (or 1 (we) have ~z obtained an Oasement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County R _istar of Deeds, as D ument No. SiUNATUNE OF OWNER SICrNATURE OF CO-OWNER (IF APPL C LE) GATE SIONEp DATE SIGNED DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR F,N%D ` P.O. BOX 7969 HUIMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (H63.09(1) & Chapter 145.045) St_ LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: Nz~ 1/4 '/a = . /T 'N/R j E (or/vv~ z COUNTY: OWNER'S/BUYER'S NAME:I MAILING ADDRESS: r; USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ~'~j PROFILE DESCRIPTIONS: PERCOLATION TESTS: ZResidence New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system , J J 1/f / 66 G "/L- "r an,- } CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)~ 15 ❑S ❑u ❑S ❑u ❑S ❑u ❑S ❑u ❑S ❑l If Percolation Tests are NOT required DESIGN RATE <)c If any portion of the tested area is in the under s.H63.09(5)(b), indicate: `e' -,,c f t Floodplain, indicate Floodplain elevation: X PROFILE DESCRIPTIONS f BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i. ? J•; / , /Y ;'vV . / t l., chi U ~ t _ _7 ~ C_ C;/ rc f r 3 cy' Tit 6 C' B / PLC c x.67 r dE.~' c; cr,~ 13- B /r Ao- G - 01 A & T v tl-- S 7 A) C' 61 f,C I ec~ 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 PERINCH P ALL So c"4 R r I P s i < 1~ / S r~ 1 / wJ ~d ox I ax 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. 3oTf 7 0/ />Z2) Z ii S~ ~y* lCi t~ cIL!. r~'~ : f~~7L/ ✓ S ~y~ SYSTEM ELEVATION ~i6 w Z,'L4 of l~o,r'F E : : : T This test life APPOVED u1 for a conventional 6e ;tics stem, : 3 ~ E 3 3 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: ROWS= TESTMIM CO. ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNATURE" RTC. ~ 3 O'N L_L RD HUD v ✓ 5-02482 SON, tiVI 54016 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 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