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CROIX COUNTY, WLSCONSIN. _ SUBDIV LSLON LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements oP H63 SHOW EVERYTHING WITHIN 100 FKET OF SYSTEM 1 _ i i i i > I 1 _T- i I I I ~ . i i Indi_ at N r h rrr w BENCHMARK: (Permanent reference Point) Describe: _ f Elevation of vortical reference pu,irtt: ~Slope at Site: --f- / SEPTIC: TANK: Manul acturer Liquid Capacity fir, , J Number of rings on cover L -lank manholq cover eievati T - r - 'l'ank Wet Elevation: c ' Tank Outlet Elevation:/ PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cycle gallons; Total capacity of diStributlou lines -gallon: Size of purnp__- _ - head; gallon per minute horsepower b , rand name of pump and model number 'type of warning device - BOLDING TANK: Mauufacturer__ Number of gallons Elevation of manhole cover > Type of warning device SEEPAGE PIT SIZE;___ _ Number of pits feet diameter feet liquid depth- seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SEEPAGI BED SIZE: number of lineS width length ~ the deptl SEEPAGE TRENCH: width - - - Length------------- PLRCOL TION RA'TU'-/... AREA REQUIRED - AREA AS BUIL'T~ i INSPECTOR ' DATED PLUMBER ON JOB_L LICENSE NUMBER_,~ > , - i DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.C BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 4ACONVENTIONAL ❑ALTERNATIVE State PlanLD.N„mber (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mounds (21y NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER'. INSPECTION DATE Mitehe.et Ke tte~ R. R. 2, New Richmond, LU f BENCH MARK (Perma ne.t reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PT. ELEV.' SW SF, Section 2, T37N-R78W, Town 06 Stcuc PItai ke Na- of Plumber. MP/MPRSW No. Cou my Sanitary Pe-1 Number: Cat Poweu 7563 S~. Cnoix 49433 SEPTIC TANK/HOLDING TA K: MANUFACTURER. LIQUID CAPACITY. TANK . TANK OUTLET ELEV.. WARNING LABEL LO KING OVER YES ❑NO YES ❑NO I, ( BEDDING: JV IA.. VENT MATL(. HIGH WATER NUMBS OF OAD PROPERTY WELL. BUILDING VENT TO FRESH k ALARM LIN AIR INLET. ❑ YES ~JgO ❑YES ❑ NO NFEET DOSING C HA BER: MANUFACTURER BEDDING. LIOU10 CAP PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED'. PROVIDED'. ❑YES ❑NO YES NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING (VENT TO FRESH LINE AIR INLET. (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check thesoil moisture at the depth of lowin ILEN(, TIIJDIAMETER f M TERI L AN MARKING or excavation. (If soil can be rolled into a wire, constructions all cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF IDIST11 PIPE SPACING COVER INSIUE DIA uPITS JLIQUID BED/TRENCH Li t ( TRENCHES ( MLA PIT DEPTH DIMENSIONS j~ GRAVEL DFPTII FILL DEPTH IDISTR PIPE DISTR. PIPE DISTR. PIPE MA RIAL. NO. DI R. NUMBER OF PROPERTY WELL BUIL N - VENT TO RESH BELOW P PES ABO.V COVER. ELEV. INLET EL END 2 PIPES FEET FROM !PROPERTY AI L ~~~`CCCfff.1 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH: BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED E DED MULCHED CENTER EDGES ❑YES ❑NO ❑YES ❑NO ❑Y S ❑NO PRESSURIZED DISTRIBUTION SYSTEM: / WIDTH. LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FIL DEPTH ABOVE COVER. BED/TRENCH TRENCHES. DIMENSIONS I MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PI E DIST IBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA. ELEV.' PIPES DIA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VER CAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL'. BUILDING;. FEET FROM LINE. ❑YES ❑NO ❑YES ❑NO NEAREST 1 °0 ~i 00~ Sketch System on tain in cou y file for audit Reverse Side. - SIGN E. TITLE. DILHR SBD 6710 (R. 01/82) '1 Wisconsin APPLICATION FOR SANITARY PERMIT COUNTY },DILHR (PLB 67) OEPRRT OF TEnT UNIFORM SANITARY PERMIT # In DUSTRY. LRBOR 6 HUMRn RELRTIOnS / / Y -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 O NER yY , ! of MAILING ADDRESS PROPERTY LOCATION La{~~.: <<.J 1/4~, - 1/4, S 2 , TN, R (or) W TOWN F: S-TCL( CQ C(a, LOT NUMBER 131_0)61\IUMBER ISUBDIV1S1O.N NAME NEAREST ROAD, LAKE OR LANDMARK STATk PLAN I.D. NUMBER Z 4 14 /14 TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. 1' ❑ Public (Specify): 1 THIS PERMIT IS FOR A: .F_'J 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. 7 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 - El 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 aC0 i Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: -C~LJ t T ~S 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): F S ~lJ d Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installati f the private sewage system shown on the attached plans. Name of Plumber (Print);__ Sign W MPRSW No.: Phone Number: Plumber's Address: Name of Designer: . CL~ C, COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: F/ee:/ Date: / ❑ Disapproved 7r ti (G',W' 6 w~~ YApproved ❑ Owner Given Initial 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 +s r i 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. Norm - S T C 100 Owner of Property-4-)a', ~C' 1-\ ; "f P1 .Location of Property ~ pLtr ~ ~ ~~N kW Section T Township Mailing Address +~-f- 77~r~ Subdivision Name Lot Number v Previous Owner of Property-]L.0 ~ E Total Size of Parcel 1 `~G~(, 4< I' S Date Parcel Was Created Are all corners identifiable? Yes No Include with this application one of the followiri~,,; .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION (We) certify that all statements on this form are true to the best of my (our), knowledge; that L (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. s G' ; and that I (we) presently own the proposed site for the sewa4&'- sal system Cor 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. -3y9 r~ ) SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED f 7HUMft PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DUSTRY, DIVISION BOR A~^ PERCOLATION TESTS (115) MADISON WI 53707 RELATIONS CATION: SECTION: / TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 1/454 /T 1 3! N/RI (or W n S rAR PRAIR/E ~L COUNTY: OWNER'S BUYER'S NA E: MAILING ADDRESS: C86a Ke'sE L50 J~'fT. Z E 1 r. S¢ 7 USE DATE OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence New ❑Replace 6 ~r & RATING: S= Site suitable for system U= Site unsuitable for system 7 CONVENTIONAL: MOUND: IN-GROUND-PRESS URE:SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ©S ❑u XS ou ®S ❑u ®S ❑u EIS ®u C~~AtItF,nn1a~ If Percolation Tests are NOT re q d JD SIGN RATE: SYSTEM EL V. Q SS If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 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.) B- y9. a3 414W- ? O-/,;I 3nsL /,a- zR w CoB B 2 >s y 0-// /r q.R MACS M.67 F 9 g. B ¢ '7v? " 97 S /!//E 0-1 sc -4 cs 41-53 s w Ccr; 5 ~-7, , s -r1 B- ~tfo. /Uca > 0--139,5L. 13-49,9, C5 608. VLAS B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- P- P P_ PLAN VIEW: 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 slop. SYSTEM ELEVATION `llk. ~ 97,5` ORt~. $1 I fl P0 ME $~15E v if 03 D " § ~cVE ~ t I _ 8211 I i< 85 ARC A 4 fl DvE S►ZF c r >c SAC74ES. the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specifie in the Wisconsin Admimistrative 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): 7C. rx C/J. Ll;(.K ~j ~ 4 - -3 1 CST SLCINA,TU DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DI LHR-SB D-6395 IN. 03/81) ad* t i Pr P moo w! r b On GCs, Ad a 1 = 4 1,Af f / / iiiv1ra- C l~llei(S e- 3p- 'Id - - __T_ ! - Y i Pin , i i i IL OP J ID qy GL- tS~ i , i i