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HomeMy WebLinkAbout261-1211-29-000 (2) 0 0 0Ca0 1E-00 d O C f I O o cD ~1 .d. ; C CD m 7, n 3 ^r 7 CD CD ~ N A p lD '6 A~ • Z C~ C 'v M CD + m 1 3 3 3 - 3 3 d o_.. ° o m v o _ 0 r l I cn Q0 C=) CA CD CD N a N C-- O Q tD Q= O M ^ 07 7 7 p O co 7 7 Z Q O 0) y \Z N N N CA CD m O N CD 1 v °o C m 7 CD n m x 0 T ~ O1 -0 0 o CD ! O n °O 3 CD =r Q ° R Z C W N .y. H Q0 3 `3 ~1 C O D] C O !~\I` c . ;!s CD 7d Z Z D a° m u) D a 0) a (o c~ • G D W a m m G. a ~ -r CD Z IE. o o C n o o C) O lz N 3 0 oD m o d j j A CD A j m "*Mat Z co cD _ tQ s > to co CD CD co OD r- cn 00 00 :E W 4~ 41 o "at • r o H O O O o z O O O F N N N 0 N P (o o rc3: In N fR n F ~ 3 < 3 a) , CD m rn cr 'o a C) CZ) CD 0 CD n D C) D CL !V d y 01 N ICI O 00 W N N CL Z oo z w z ° Z z ~-1 41 w m O D a 0 D CD a Z rn j CD CD h• _ p a N A CD Co CD Chi f0 CD CD C CD CD b cwt ~j m ° w m n 3 3 CD Cp (1-- CD Z z o a N a n a A Z o_ C^.~ m O p' M co wv I m~ m o. (D m o z 3 0 U) 0° °O Mm 00 3 3 N N p CD CD O O O CD > 7: Q 3 O ~-0 O 7 d 3 CD 0), cl) j, -n CD 00- 3 CD CD _ c CL _ o o w oo N o = Z o ° z a 0 r') cn o ~ o mo v, ~j @ g, o CD - :N D) CD ,Z CD --MNpFj td' N NN C (m O N CD COi.1 CA s CDZ CD n CD p' -0 CD ,a ~rtl- O Q O O O CL M S D) cr f 0 = O CD C/O) o y CD O O En CAD 7 CD o N v A =r =r a 7C N'O C 3. °C q O 7 O-0 O CD CD Cn CD 0 0 m o N O to N A (D CD 77-, CD COD OD S n : w co CL n 'O C+a O O - 0) 5) CD CD ti 0 Cl) E; q =r CD C CCD / -C CD W N O O O CD CL 3 Cl eD a Cl O co CD A O. ? 'O N O A O~ O N CD CD 4 Q V A \ fA 0 fA 0 w ya ) ` C °O L y ti Parcel 261-1211-29-000 01/31/2007 02:24 PM PAGE 1 OF 1 Alt. Parcel 925-004-010 261 - CITY OF NEW RICHMOND 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 - COX, BRIAN A & PAMELA S BRIAN A & PAMELA S COX 1400 E HWY 64 NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1400 E HWY 64 SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Lanai Description: Acres: 7.880 Plat: N/A-NOT AVAILABLE lIP OF THE SE SE SEC 25 T31N R18W DESC AS Block/Condo Bldg: LOTS 1 & 2 CSM 5/1283 ALSO COM SW COR SD L07-Z,TH S ALG E ROW STH 65 TO ITS._ _ Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) ('LI INTERSECTION WITH N LN STH 64; TH E ALG 25-31N-18W N ROW LN STH 64 TO THE SW COR OF SD LOT 1;THN01 DEGE11317';THN82DEG i more- Notes: ' Parcel History: Date Doc # Vol/Page Type 07/23/1997 1151/191 WD 07/23/1997 1113/060 WD 07/23/1997 939/410 07/23/1997 787/513 2006 SUMMARY Bill Fair Market Value: Assessed with: 186567 1,823,600 Valuations: Last Changed: 05/17/2002 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 7.880 275,000 1,253,000 1,528,000 NO Totals for 2006: General Property 7.880 275,000 1,253,000 1,528,000 Woodland 0.000 0 0 Totals for 2005: General Property 7.880 275,000 1,253,000 1,528,000 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 Parcel 038-1104-30-000 01/31/2007 10:06 AM PAGE 1 OF 1 Alt. Parcel 25.31.18.4361 038 - TOWN OF STAR PRAIRIE 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 - COX, BRIAN A & PAMELA S BRIAN A & PAMELA S COX ANNEXED Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 430 S KNOWLES AVE SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.596 Plat: N/A-NOT AVAILABLE SEC 25 T31 N R18W .596AC SE SE LOT 2 OF Block/Condo Bldg: CSM 5/1283 ANNEXED TO CITY OF NEW RICHMOND (1246/344-#561171) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 25-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1234/156 WD 07/23/1997 1148/45 LC 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 02/27/1998 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: 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 Parcel 038-1104-30-000 01/31/2007 10:05 AM PAGE 1 OF 1 Parcel 038-1103-60-000 01/31/2007 10:02 AM PAGE 1 OF 1 Alt. Parcel 25.31.18.436B 038 - TOWN OF STAR PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner O - COX, BRIAN A & PAMELA S BRIAN A & PAMELA S COX ANNEXED Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 430 S KNOWLES AVE SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 6.344 Plat: N/A-NOT AVAILABLE SEC 25 T31 N R1 8W 6.344AC SE SE LOT 1 OF Block/Condo Bldg: CSM 5/1283 ANNEXED TO CITY OF NEW RICHMOND(1246/344-#561171) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 25-31N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1234/156 WD 07/23/1997 1148/45 07/23/1997 835/164 07/23/1997 615/542 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 02/27/1998 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: 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 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT 1 D OWNER TOWNSHIP SEC. T 1 1 N- W ADDRESS ST. CROIX COUNTY, WISCONSIN i SUBDIVISION LOT LOT SIZE i.~ PLAN VIEW !)ist<uIc~s <u(i' 11iIII II•1~~!t r~~'I uir111I'utof iltiW ~'VI!I:Y'I'lll (JC W) TIHN i 00 ~'FF I M' Y i'1'I':M t ~ I i I i /'I r { N I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: f~. Proposed slope at site: SEPTIC TANS: Manufacturer: Liquid Capacity: f' Number of rings used:- Tank manhole cover elevation: Tank Inlet Elevation:.`•7~', Tank Outlet Elevation: f' Number of feet from nearest Road: Front,0Side,/ Rear, 0 feet From nearest property line Front,0Side,("~ Rear,0 feet Number of feet from: well building: j (Include this information of the above plot plan)( 2 reference dimensions to septic tank) til hl? SEE RFVFRSE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size i i Elevation of inlet: 7 ~ Bottom ,f -ak elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: i Number of feet from nearest property line: Front, O Side, Q Rear, Ft.-'f Number of feet from well: - s 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 :-eet from building: Number of feet from nearest road: Alarm ranufacturer: Inspec,t-ZFr.: Dated: ~Plumber on job: License Number:. 3/84:mj OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS DEP4RTVIAN RELATIONS DIVISION LOBORo9 PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING 'MApB~W I 53707 (CONVENTIONAL ❑ALTERNATIVE statePlan edl)D.Number (If assign ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound y Jp 6 9 INSPECTION DATE OF PERMIT HOLDER: ADDRESS OF PLDER'. iuane Joh"on R. R. w Richmon d, W1 REF. PT. ELE V.. J CST REF PT. ELEv &NCH MARK (Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN. SE4 o SE% o4 Section 25, T31N-R18W, Town o~ StafL Pte.a-i-Lie Sanitary Permit Number Name of Plumber MP/MPRSW N,, County 1563 St. Ctcoix 54900 Cat Pvwetuv, SEPTIC TANK/HOLDING TANK: MANUFACTURER. r~ LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV PWRARNIN DLABEL EOCJING C, ER PH( YES ❑ N O ❑ Y S N NUMBER OF ROAD. PROPERT WELL BUILDING: JVENT TOF ESH AIR INLET. BEDDING: VENT DIA.. VENT MAT L. HIGH WATER LINE: _ ALARM. FEET FROM ❑ NO [:]YES ❑NO ❑YES NEAREST ' DOSING CHAMBER: MANUFACTURER . BEDDING . LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUF/AC7 1REN WARNING LABEL LOCKING COVER P IDED: PROVIDED. f~7F pu L' J~ ~.-1 l c ❑YES ❑NO YES ❑NO ❑YES ❑NO PROPERTY WELL BUILDING VENT TO FRESH GALLONS PER CYCLE: JPUMP AND CONTROLS OPEHATIONAL NUMBER OF LINE I AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO NEAREST LENG rH DIAMETER MAT ERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 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: NSIDE DIA xPlrs unulD WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER PIT DEPTH'. BED/TRENCH TRENCHES MATERIAL` DIMENSIONS , ERTY WELL BUILDING VENT TO FRESH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. DISTR. NUMBER OF PLIRNEOP U AIR NLET' BELOwPIPES ABOVE COVEN ELEVNLFT ELEV END - PIPES FEET FROM F!`y L) r ( Li ` 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 ❑ND PERMANENT MARKERS OBSERVATION WELLS SOIL COVER TEXTURE ❑YES ❑NO ❑YES ❑NO I, SEEDED MULCHED. i DEPTH OVER TRENCH BED DEPTH OVER TRENC H BED DEPTH OF TOPSOIL SODDED CENTER EDGES ❑YES ❑ND ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER WIDTH LENGTH TREONCHES: LATERAL SPACING. GRAVEL D EPTH BELOW PIPE. BED/TRENCH DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING PIPES DIA.: . ELEV. ELEV. DIA.. ELEV P ELEVATION AND DISTRI 3U1 ION COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY PLANS. ❑YES ❑NO ❑YES ❑NO FN BER OF PROPERTY WELLBUILDINGCOMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. FROM LINEYES ❑ NO ❑ YES NO REST o J i `I I 0 2- I I rl V u y n county file for audit. Sketch System on 4 Reverse Side. i TITLE: ' SIGNATU i DILHR SBD 6710 (R. 01/82) , .i - i-} i Wisconsin APPLICATION FOR SANITARY PERMIT . ~ DILHR COUNTY (PLB 67) UNIFORM SANITARY PERMIT # ~ OEGRRTTEnT OF - IrIOUSTRV,LRSOR 6 HUM) nRELRT10r15 3'4/9,00 -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 OWNE MAILING ADDRE S PROPERTY LOCATION CITY: V ILL-AG E: L N R (Or) VII TOWN OF: / i 14( i 1/4, , CDT NUJVIBER JBSUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER f X/ 1/ TYPE OF BUILDING OR USE SERVED / f 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): i THIS PERMIT IS FOR A: ❑ New System Q Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification 'r IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. I I ~ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank I El System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy t P ❑ 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. A Total # of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic t Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity j Manufacturer: ; 1~ 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: 0-1 9 PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: / 21 / - 1 Private ❑ Joint ❑ Public # I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name -of Pl~imber (Print):] / Sya~ur/ea MP/MPRSW No.: Phone Number; a Plumber's Address: / Name of Designer: / / 4 ✓ _v i COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved a"d ❑ Owner Given Initial XApproved 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 H G y t~ S T C - 105 r ti o SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County d 1 y OWNER/BUYER ~~1 ROUTE/BOX NUMBERr -Fire Number 7. LP CITY/STAT'E , r PROPERTY LOCAT'ION t 2, Section N. R 'l Town of St. Croix County, Subdivision Lot number _ I Improper use and maintenance of your septic system could result in I 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 1umper. What you put into the system can affect the function of the septic tank as a treat- went stage in the waste disposal system. St. Croix County residents ma be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, was which w waas in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new stems agree to keep their systems properly maintained The property owner agrees to submit to St. Croix County Zoning 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 sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. o I/WE, the undersigned, have read the above requirements and agree cn ac to maintain the private sewage disposal system in accordance with r the standards set forth, herein, as set by the Wisconsin Depart- b meat 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. SIGNED DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS Vent Cap Weather Proof Junction Box Approved Locking Manhole Cover 12" Min 4" C.I. ' , Vent Pipe Final 4" Ptin Grade t Conduit 18" Min 1 18" Min + ail r t i Inlet Approved Approved voo o, Joint w/ 0jitio0aul A Joints w/ C.. Pipe ~t a• C.I. Pipe Extending l~rs Extending 3' Onto ';;Qkvklarm 3' Onto Solid On B Solid Ground, Ground C . Pump _ _ 4 _ _L % O f f ra Concrete Block D SPECIFICATIONS TANK PUMP ",3 r ~ Manufacturer: Manufacturer ( Tank Material: Model Number: Tank Size: Gallons Switch TyDe Total Dynamic Head: FT CAPACITIES Pump Discharge Rate: ' GPM Total Daily Effluent: Gallons A - G or '4 7<^ Gallons Number of Doses: f= Per Day B = or Gallons Dose Volume: ; Gallons C or Gallons Notes: 1. See pump curve for D = < or Gallons additional performance Total Tank information. Capacity Required Gallons 2. Pump and alarm are to be installed on separate circuits ALARM as per ILHHRR 16.19 WAC. Manufacturer: SIGNED: f Model Number: LICENSE NUMBER : /~C j~ Switch Type <l - /ci DATE: ~'3 DEPARTNiENT Ur REPORT ON SOIL BORINGS AND SAFETY BUILD!N INDUSTRY, DIVISION N LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 76 ON WI 3707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP MUNICIPALITY: LOT NO.:BLK SUBDIV OON NAME: - /T'/ N/RCS (o~W 4: 1 1 40 COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: ~7, 2 If ) j USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ❑New ©Replace I RATING: S= Site suitable for system U= Site unsuitable for system A"), CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) El S ❑U H S ❑U S ❑U ❑ S A 0 S DU s If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the f . under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ON DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATI OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK..)) B- C b, .9 i ' 7 L ' 47 B- B- B- j 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 i P- P- P_ r P- P- P (t? 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 - z' Tr )0! n ! I ---I j I C I ~ I ~ +f j I ! I i2 r~ ~ z I I i I I t i ' 1 I I ' i i ! r j _ I tom'. - ; ; i I ~ / i o ( 1 t • -A i 1, the undersigned, hereby certify that the soil tests reporte on this ~form were made by me in accord with the pro sand metho s specified in he Wisconsin Administrative Code, and that the data recorded and the location best of y edge and belief. j , NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE UMBER (optional): " p CST NATURE: ')ISTRIBLI PION: C iquta! a rt one copy to Local Authority, Prope„j Ownrr ood So i Tester a 0?1 OVER - APPLICAT [ON FOR SANITARY PQRMIT S T C - 100 'I'llis application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only reswlt in delays of the permit issuance. Should this development be intended for resale by owner contractor,("spec house_"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - i Owner of Property,)`' IL, of Property, i` 1, Section T J N - R W Township Malting Address Subdivision Name - L.ot Number L-4 Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes 21 No Volume and Page Number tz3 - as recorded with the Register of Deeds TNCLUDF WTTH THIS APPLICA`T ON ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. AOPLRTV OWNER CERTIFICATION I jv) ventij y that aXX A-tatemen t,5 on thjA Aonm ate_ true, to the bw of my (out) hnowtedge.; that I (we) am (ate) the ownet(A) of the pnopenty d"eti_bed in ,thit6 in.Aonmation loom, by v.tntue of a watrtanty deed neeoaded in the. Office of the County RegAtet of De.edA at, Document No. 3 S and that I (we) pnmeyW-y own the pnopoAe.d Aite {ion the Aewage_ spoAaT AyAtem No I (we) have, obtained an eaAemen,t, to nun with the above dmo"i_be.d pnopenty, lot the. corottuc,t on of said AyAtem, and the Aame hay been dud-2 ne.conde_d in the 0A{&e- o{ the County Reyi6ten of DeM6, aA Document No. ) . 4 , GNATURF. OF OW FR SIGNATURE. OF CO-OWNER (IF APPLICABLE) )ATE SIGNED DATE SIGNED W1711, v J ~l . ! f• J .~iJ,tl' r.~ ~ 1 ~ L~ ~ , ~ l1, t _ X-1~i~11J~~...-. /j} _ f i I i I I ! j _ I / i _ # L rV'. ..11-~lGd-~~l^' _ ,~.~i/~'Q.l~.f.~ - . _ - - - i i f• J ~ J :r• i ~ I w : / i -...~11r...:!` _!_~.=~aC--1~c1_s~..~.,c'l~.,F_bA~+.!_r..✓ i _ _ ~ ~ -I ' I I ~ ~.I, ~ 7- I - - 00 A CO or ok I i } 3 0 i I I IuL1 i , Yll) I _ i I : v I -1 .11 r I A 1 I I I I Fr- I 17 trL . I r- l.. 1 ' U ; Department of Industry, Labor and Human Relations -LumconslnSion of Safety & Buildings ~ D I L H R Bureau of Plumbing oEaRRTmEnTOF n /~9 P.O. Box 7969 - InOU5TR4,LRBOR&HUMRnRELRT1on5 /l Madison, WI 53707 a NOV CF1l/ f el. (608) 266-3815 .J W& 19 LL CORRESPONDENCE REFER TO PLAN DENTIFICATION NO. 5~0/ t ~!30 rs~ q~ boo NAME OF PROJEC ~ S VATE SEW L - ❑ GENERAL PLUMBING PLANS Fee Received: LOCATION Priority Plan Review Only 1 1~ CITY OR TOWN COUNTY. T ✓A ! ~/i Examinatio of plumbing plans an ifications- r this project has been completed. In accord with Chapter 145, Wiscons in 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. Tne 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. begirt: 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. Sincerely, For Private Sewage Systems Only: F This approval is valid for two years or it will he valid until he expi,-ation date of the initial James Sarg4t-,~' sanitary perniit. Bureau Dire or LAN REVIEWED BY: K6~A /I DATE: cc: PS - OWS Owner H & R & Rec. San. Section L Plumber Bur. of Health Fac. & Services ounty Other DILHR SBD-6099 (R. 05/82) 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 MADISON, WI 53707 608-266-3815 DATE: PROJECT: 31, b -ar Prai r-i: 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. "i ❑ 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. V1. 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). i ❑ 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. I 6678 (9/81) (Plb 100a) STATE OF WISCONSIN DILHR ~'~9 etach 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 t « i MADISON, WI 53707 608-266-3815 DATE: [~n PROJECT: N01, , 'tar Prair 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 $660' 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 ll. 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. ❑ Plan view of system. ❑ Plot plan. ances to any building, wells, water service piping, water 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. Ill. 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.