HomeMy WebLinkAbout022-1069-40-000
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Parcel 022-1069-40-000 12/22/2005 09:25 AM
PAGE 1 OF 1
Alt. Parcel 25.28.18.387A2 022 -TOWN OF KINNICKINN CC
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - LEBRECK, CAROL
CAROLLEBRECK
1455 EVERGREEN DR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 1455 EVERGREEN DR
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 16.440 Plat: N/A-NOT AVAILABLE
SEC 25 T28N R18W 16.44A IN SW NE LOT 2 Block/Condo Bldg:
CSM VOL 3/848
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
25-28N-18W
Notes: i j~~ i t r Ql~h- Parcel History:
T't It Date Doc # Vol/Page Type
I ~-7 vi°U L L (rte-
.
LC
2005 SUMMARY Bill Fair Market Value: Assessed with: ~Z ~S 3c1
143711 207,800 W, 1)
mr
Valuations: Last Changed: -6 rw/11/2005
Description Class Acres Land Improve Total State Reas n
RESIDENTIAL G1 1.440 40,000 170,100 210,100 NO
ENTERED BEFORE'05 CLOSE W8 15.000 90,000 0 90,000 NO
Totals for 2005:
General Property 1.440 40,000 170,100 210,100
U
Woodland 15.000 90,000 90,000
4)" '
Totals for 2004:
General Property 1.440 20,000 125,700 145,700
Woodland 15.000 37,500 37,500
Lottery Credit: Claim Count: 1 Certification Date: Batch 201
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
EH Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. B 09, DISON, WI CONSIN 53701
LOCATION: ` ~'/4, Section_,, ,T' 'TN,R11E (or) Al Township or Municipality { i1 hl 1 nl L'
Lot No. , Block No. County 5i, ~V y i x
er PA's e r Subdivision Name
Owner's/Buyers Name: Kd 'I
Mailing Address:_ kte ! Ilt U X11,5 z, jl"_s
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW X_REPLACEM NT ALTERNATE SYSTEM j OTHER _
DATES OBSERVATIONS MADE: SOIL BORINGS MArClrl ) 5; Fl PERCOLATION TESTS ND'Ch
SOIL MAP SHEET'__& NAME OF SOIL MAP UNIT ~n ~ / dJl~O ► ~
PERCOLATION TESTS
TEST DEPTH _ CHARACTER OF SOIL A HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
Num- SINCE HOLE HOLE AFTE INTERVAL
MIN/IN
BER INCHES p THICKNE~PSS INS INCHES 1STWETTED SWELLING IN MINUTES PERIOD I PERIOD 2 PERIOD 3
P- 41
7 1,5 1, X14 )f 111,6
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES ,p !
B- p01+ - Ob ' 11 "bl Sl ,_e s LJ rn 1kv/ r.y
B- 93 ~•"I. I S " IJ 11 s~ s /yr WA s w r~
B- S, GiJ 3
B-
1` F4 C d d t r r' m` g e .
~j st're 1 5C411-r46/ r6C1__M0UA(j 5,QTfCP" 1)
PLAN V IEW (Locate percolation tests, soil bore holes and suitable soil are g.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 140 ri Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
14+~ lilac b Yeeh ~v`i
t =RE 1ev Esc
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5ev'vite l 1,~u 81 es
f`ac' 1 Ch.rrrt~1 twee
1, the undersigend, hereby certify that the soil As 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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) f 0 A Q S 4JCt K Certification No. ~~L7
~e S
Address tu-er
Name of installer if known
Copy A -Local Authoa ity CST Signatura_
I rcel 022-1069-80-000 04/16/2007 03:14 PM
PAGE 1 OF 1
Alt. Parcel 25.28.18.387D 022 - TOWN OF KINNICKINNIC
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 5
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
RETIRED HUSER O - HUSER, RETIRED
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 25 T28N R18W 2A IN SW NE STRIP Block/Condo Bldg:
EXTENDING ACROSS N SIDE OF SW NE LYING N
OF CSM 3/848 ROAD NOT VALUED Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
25-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
S T C - 104
AS BUILT SANITARY SYSTEM REPk 9
OWNER TOWNSHIP wJ
Co SEC. ; T N-R W
ADDRESS r. ST. CROIX COUNTY, WISCONSIN
e
SUBDIVISION LOT LOT SIZE l
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4j
_ ~ poe
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site: _ T
SEPTIC TANK: Manufacturer: ~.4'e"? Liquid Capacity: /r;
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,O Rear, O feet
From nearest property line Front,0 Side,0 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions ro st~~ric t~1nl<)
PUMP CHAMBER
Manufacturer: Liquid Capacity: Q
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, Side, O Rear, 0 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:
Number of feet from nearest property line: Front, O Side, O Rear, 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 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: ' s
Dated: Plumber on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDIN
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
❑ CONVENTIONAL ® ALTERNATIVE statePlan D.N~mbe,.
(If assigned)
D Holding Tank ❑ In-Ground Pressure ❑ Mound $402000
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Carol Le Breck 905 State St.#2, River Falls, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. BEE. PT. ELEV.. CST REF. PL ELEV
SW NE, Section 25, T28N-R18W, Town of Kinnickinnic
Name ,f Plumber. JMP/MPRSW N,, County Sanitary Permit Number.
Paul Cudd 2739 St. Croix 49498
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV~JWARNI G LABEL LO CKING COVER
EDPROVIDEDES ENO OYES ENO
BEDDING: VENT CIA`s F VENT MAT L. HIGH WATER NUMBER OF I ROAD PROPERTY WELL- BUILDING VENT TO FRESH
ALARM. FEET FROM i? LINeLAIR INLEr.
DYES TONG DYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PU MP; SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
l ' PROVIDED PROVIDED
W -QI DYES NO 75) 5I• d Cerr YES ENO [~+YES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN 14~ FEET FROM LI"~TE AIR INLET
PUMP ON AND OFF) ZYES NO NEAREST-f '7'
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IAMER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE ~O
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER JINSIDI DIA. ttp1TS LIQUID
BED/TRENCH TRENCHES MATERIAL. PIT DEPT"
DIMENSIONS
GHAVFL DFPTH FILL DEPTH DPIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END 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-
X~y meets the criteria for medium sand. TIONS MEASURED.
1~}YES ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBSEHVATION WF LLS
ES ENO YES ENO
DEPTH OVER TRENCH.' BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES S , S EYES F-.~-NO YES ENO C YES NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH L1 7 TRENCHES: S
DIMENSIONS T
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
EL V ELEV.. DIA , ELEV.'. PIPES. DIA.:
ELEVATION AND 4;.Ei Z
DISTRIBUI ION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
1
7,89 ENO
YES fEl NOYES
COMMENTS: ERMANENT MARKERS: SERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDI NG.
FEET FROM LI"~~ f by
YES D NO YYES ❑ NO NEAREST
Sketch System on R.g unty file for audit.
Reverse Side.
SIGNAT - TITLE.
DILHR SBD 6710 (R. 01/82)
~ I Wisconsin APPLICATION FOR SANITARY PERMIT
DILHR COUNTY
J
oERRRTmEnTOR= (PLB 67) UNIFORM SANITARY PERMIT #
- InOUSTRV,LRBOR6HUmRn RELRT,-nS / I
-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
PROPERTY OWNER MAILING ADDRESS
C, !4
PROPERTY LOCATION
`b 1 14 1/4, S
115, , N, FIV E (o w WN OF' G_ - 4;_ '
LOT NUM ER BLOCK UM SUBDIVISION NAME NEA ST D, L.,,.. OR LANDMAHK STA PL,-,: `.:i. NUMBER
2ooa
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
L -3-
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 / 9 ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System In Fi1~C'1~L ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
Ej A
❑ 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/B+pberref~r
Holding Tank capacity
Manufacturer: c7
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 /000 ✓
Lift Pump/Si O &_1 I
Manufacturer: e hC_
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Z Z Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
N of Plumber (Print ' Signatur [AoW/MPRSVV No.: Phone Number:
. l
lumber' Address:
1A tel Name of Designer:.
~J 4 ~C
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
1
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 liublic 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.
v.
S T C - 105 y
r -SEPTIC.. 1ANE_ MAINTENANCE AGREEMENT o
St. Croix County
E'`1
r
OWNEK/IiUYEK_ -AI OL.. E - ~~K---- -
I,
~as ~ Fire
ROUTE /!SOX NUMB Elk I-0-te St Number
I- L -5
NE !4, Section a '1' YN, K lYW,
i
Town of K 9 /nW /St Croix County,
Subdivision Lot number 77'V0
~er-fi~iec~ ~UrV -E I~ V2e'ar ~n
l 1
a-s ~c ne 3s9
Improper use and maintenance of yu'ur~sel'tiC 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 ,u in )er. 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 maw 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 rcquir.-meat that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zunin, 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 sludgeandtscum.
Certification form will be sent approximately 30 days }
0
three year expiration.
G
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with v
the standards set forth, herein, as set by the Wisconsin Depart-
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.
SIC -D
D ATE
Z9
t
St. Cr•oix County Zon-ng Office
N.O. Lox 98
11ammor d, W1 54015
71 5-7~ 6-22311 or 715-425-8363
n, date and return to above address.
curls - _
Dwner of Property ~iu C,
.Location of Property ~1N '4, Section T a N R--/,? W
Township K I N /IJ C IA) l i r -
C
06 6
?wiling Ad6 r e s s
r- I a --/Is VV15
- -
5.:bdivision 'game
Lot Number 40 /too ca) 07 62.+'1~t,~c~ ~yrUe~.~ C
Previous Owner of Property ~C~G E,e y- /6J
Total Size of Parcel b L'CC- rC
Date Parcel ;has Created- A2-0 t 7
Are all corners identifiable? x Yes No
Include with.this application one of the following:
.Certified Survey Map
. Deed
.Land Contract, or
.Other Legal Document which describes the property
y- 0
42 C S - C4 `2- /7
OERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (W)
knowledge; that I (me) am (an) the owner* 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. 3 9F2 `f tf J ; and that I (*W)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, 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 Register of Deeds, as Document No.
SIGNATURE OF OWNER SiGNATuRE OF CO-OWNER (It APPLICABLE)
9 ~Z//
D TIE SIGNED IGNED
DATE S
Department of Industry, Labor and Human Relations
wisconsin Division of Safety & Buildings
DILHR - Bureau of Plumbing
P.O. Box 7969
1~)
oevcar+T
%Enr of Madison, WI 53707
- In0lISTRV, LfiB0R6MUTRn REIFTI0ns
Tel. (608) 266-3815
~~7~8 IN ALL CORRESPONDENCE
r' REFER TO PLAN
IDENTIFICATION NO.
PNAE OF P OJECT
_ RIVA E SEWAGE ONLY -
Fee Received:
❑ GENERAL PLUMBING PLANS ea z
Priority Plan Review Only
LO AT~ON
CITY R TOWN CY
Examination of plumbing plans H-Untl or this project has been
completed. In accord with Chapter 145, Wisconsin Statutes and the Wisconsin
Administrative Code, the plumbing plans and specifications are approved
contingent upon compliance with the stipulations shown on the plans. Please
review your code for the requirements of each code section noted.
The licensed plumber responsible for this installation shall keep at the
construction site one set of plans bearing the department's stamp of approval.
The installer shall also notify the appropriate inspector of wner required
inspections are to be made.
In granting this approval, the Division of Safety and Buildings does not hold
itself liable for any defects in plans or specifications, plan omissions or
examination oversight, and reserves the right to order changes or additions if
necessary.
This approval is based on Wisconsin Administrative Code requirements. It
shall be necessary to obtain and fulfill the permit requirements of the city,
village, township or county in which this installation is to be made. Failure
to obtain local permits will automatically void this approval.
For Private Sewage Systems Only:
Sincerely, / This approval is vaid for two
years or it wA to vaad unto
~Bju :`~ttte expiration date of the initial
es Sargit_ sanitary permit.
reau Dire or
LA E:
N REV~WED DA
cc: DPS WS Owner H & R & Rec. San. Section
Local Pr..__ Plumber Bur. of Health Fac. & Services
Other
DILHR SBD-6099 (R. 05/82)
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SBD 6678 (9/81) (Plb 100a)
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 178
Any Return Correspondence P.O. BOX 7969
x., r 3i MADISON, WI 53707
' 608-266-3815
DATE: PROJECT:
9
Ott ~NE,2 ,28,ri
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 $
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
II. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy)
government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data. ❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
III. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides. pumped per cycle.
❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons including
soil data. size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff.
---A
Department of Industry, Labor and Human Relations
wi"°ns'n ? Division of Safety & Buildings
C)ILHRl,Bureau of Plumbing
P.O. Box 7969
inouS~TmenT Madison, WI 53707
inousriav, Lasaa s r~umwn cLraTions
A Tel. (608) 266-3815
IN ALL CORRESPONDENCE
REFER TO PLAN
IDENTIFICATION NO.
NAME OF PROJECT/
RI ATE SEWAGE ONLY -
❑ GENERAL PLUMBING PLANS ? L Fee Received:
LO ATION Priority Plan Review Only
L C-1
ITY OR TOWN COY
Examination of plumbing plans and specifications for this project has been
completed. In accord with Chapter 145, Wisconsin Statutes and the Wisconsin
Administrative Code, the plumbing plans and specifications are approved
contingent upon compliance with the stipulations shown on the plans. Please
review your code for the requirements of each code section noted.
The licensed plumber responsible for this installation shall keep at the
construction site one set of plans bearing the department's stamp of approval.
The installer shall also notify the appropriate inspector of when required
inspections are to be made.
a nrnvnl .ii 11 ho unid anH new
(]p 1
In granting this approval, the Division of Safety and Buildings does not hold
itself liable for any defects in plans or specifications, plan omissions or
examination oversight, and reserves the right to order changes or additions if
necessary.
This approval is based on Wisconsin Administrative Code requirements. It
shall be necessary to obtain and fulfill the permit requirements of the city,
village, township or county in which this installation is to be made. Failure
to obtain local permits will automatically void this approval.
3
Sincerely, / For Private Ccwar:a Systeris Only:
This approval iS valid fcr two
years or it will be valid un!9
rzl ~ the expt-.:V,n elate of the initial
James S'o r
Bureau Dire sa.)IU.ry Pefff"it.
A-NS REVIE p Y: DA :
cc: DPS - OWS Owner H & R & Rec. San. Section
Local PI Plumber Bur. of Health Fac. & Services
cC;o;n Other
DILHR SBD-6099 (R. 05/82)
1/7
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MODEL 1JUAAbCR----S~---I~-`----
FRICTIOIJ LOSS W1T111M FORCE MA11J_--
MEASUREPALL-IT BETWEEQ PUMP OU AQD PUMP QFF-
GA,LLOIJS PUMPED PER C`~GLE------_--__.- •
LLV--I[ PUMP TAUK
n~(n►~ii►nc.i ~'i~1{--------------- wtL_ser~ Fah
SIZE OF TAUK--------------_7 go cap- z+..
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VERTICAL HEIC„HT FROM PUMP BASE 6-13 FT +
TO D I S T I I I UNWF 10 KJ flCrr 0R TRtAlC►1_____--_---,_-.-
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_
YWLET OUTLET: #"CAST IV- ~I-CV 9g40
CAST IROAJ PIPE EX• 1 ( To 3 FctT
TEIJOIAJG, 3 FEET OIJTO 1 I 1
UUDISTURHED t ROUIJD NIGH WATER
WAR►JIAJI. DEVICE
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FILL TOPSOIL
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COARSE AGGREGATE PUMP LAYER
Cross section of a mound using a bed for ow absorption area.
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