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HomeMy WebLinkAbout028-1011-50-000 St. Croix SUSAN K & RAYMOND C GILLIS Municipality: TOWN OF RUSH RIVER 405 CTY RD T Permit Number: 24102 HAMMOND WI 54015 Parcel Number: 028101150000 Alt Parcel Number: 10.28.17.5913 Site Address: 405 CTY RD T Components Component Manufacturer Description Last Next_ Status Schedule Service Service Septic Tank Septic Tank 10/19/2016 10/1912019 Current 36 Mound Mound 10/19/2016 10/191'2019 Current 36 Pump Chamber/Tank Pump 10/19/2016 10/19/2019 Current 36 Chamber/Tank Effluent Pump Effluent Pump 10/19/2016 10/19/2019 Current 36 Maintenance History Service Date Maintenance Name Gallons Pumped 10/19/2016 Darrell's Septic Service 1200 09/25/2013 Not Available 0 08/13/2009 Not Available 0 'No data found for Notices, Violations, Notes -0 C) C o a) O 3: c) ve ^ O 6 v e 0. 0 M ~ `e 0 N b O C N O z C 3 m c LL O E Q U (6 M V Q E r U) = 0 v z °°3: am o co O z v cr N m z v c N H ! ro E a~ O a) • N ~ L 0 Z Z O N E 0 y Qw LO 0 0 a 0 ~~ww a) cn co co _ ~i 0 0 0 a z •w ~aaa d O ~l 7 O fn E N N 11a N U ca a) rn oo (n 2 m Cl) v o °0 0 o co O a N N I w O M O O 7 O d W m T m N U) O O "O N w Q (n t6 O O O O O T C C? 30 O a ~ H y ~ ° co ~ o 0 ^O ,on mi o c a- o 0 0 o of E 'O N N N \ i > O fA W R M to I, v y0 c ( N O CO C N N N Z w 'O r aO m ICI cc) N fL/1 0 (n z N O O 7 E R C L • O Q' d N z N Z F- UU) r \ ~k rte, w' ~ v C~ C/] m m d 4k Q = d _ .r L L: a. Q y v I m c `M~j w E u ~ c ~ I _ 1 A U a E O co U Y p N o0 3 0 o O v~ kn rY o kn 0 0 N N N ' V I d A Q i ~ I ,0 0 c z 70- LL c 0 c ~ ty 0 E d m U m c) v a ~ a) ~ y fn O Q `V `O Z 00 O N > d m H (f) C C (7 O O Z a U U d' ! N 1= 16 In F- r Z E -o 2 c7 r O O c A U O Z Z Z N I O N co N R 1~ ~ L v C 6 5 N N = O a~ o a a > - a) E E `n H H H L ( w Z 16 w o o o o z a o N E N N m c m N N -i u N rn rn_ } w E o0 o tt: m o o _ E co a N < co O O 7 w r ~ C - N ° o n3 E O om~' a v rn c v d p C r _o c Cwi p O O E oN N U Z a _O L a; a' c a a l N E L O d' d N Z C H U5 ~ w st aj gar a V 'c c : c ~1 A ci ~ al'''o;;uo Parcel 028-1011-50-000 12/22/2005 05:03 PM PAGE 1 OF 1 Alt. Parcel 10.28.17.59B 028 - TOWN OF RUSH RIVER 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 - GILLIS, SUSAN K & RAYMOND C SUSAN K & RAYMOND C GILLIS 405 CTY RD T HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 405 CTY RD T SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE SEC 10 T28N R1 7W 5A S 685 FT OF W 318 FT Block/Condo Bldg: OF SW SW Tract(s): (Sec-Twn-Rng 401/4 1601/4) 10-28N-17W Notes: Parcel History: Date Doc # Vol/Page Type 04/03/2000 620612 1500/114 QC 07/23/1997 1074/578 WD 07/23/1997 757/327 07/23/1997 691/521 2005 SUMMARY Bill Fair Market Value: Assessed with: 82744 104,900 Valuations: Last Changed: 08/30/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 42,000 61,400 103,400 NO 05 Totals for 2005: General Property 5.000 42,000 61,400 103,400 Woodland 0.000 0 0 Totals for 2004: General Property 5.000 16,500 43,900 60,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 207 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 P-a-aa.l-. Rh e reset t o a R. R. 1 Hammond, WI 54015 Violation 6.3 Sanitary Permit 6-8-82 24102-71 8103498 4-21-82 Mound Replacement i 'PLEASANT VALLEY- RUSH RIVER T• 28 N:-R.17 W. 19 J ✓ I, b , I SEE 3I aid Pace j'.Ber C VI OR. ~rES fe tlo y ~yo C •Mc Tsse J tee. f/¢r y C t} J~ ° l y~0~ y ./cox wyC Char/ene ] U P/ea„arrtW :s . h'¢~so~ l"~C X\ A c v l T ve • ] C a/ s .e k 6a/d,~:,~ , 0 tl ~ 4\i lJ 4~ C \ ~Q ^ F'0 ~ 0 ~ ° Wayne Merritt- ~ tl ~ C3'uernser~ ¢h/~r ur:si ; v96 EQy s yep 9e /49 9i ~ ~y V 0 ~ b~ W ~ 0 ~y Dari-o/d .P Lo°c.E • BO p p 0 Farm, Inc. ~ ' Mc Lo 9h/.~ 4' ~ ~ ~l ~ ~J'v~n Q'Q~n Thon ~.ro.~• /40..36 cTohn E. N l\C 0 .Pa/P /.>Ya~ /7 s" 6.~ Lor/acne /iB 7s N/e rrrtt qtl Q~ ~ O/2 S Car'/ 94 90.59 NAAS $o Ssm¢ C 0, 73. B4 /39 S7 b 9 a yec c De/owes l tl c! .3s Da.ro/d tl , C V L a,noi e ' v,p h r-/buch l v Tho pson a C C b 0 C tl• 9/ -C l p '0 Q,'0 0 0 0 //z. s9 s.6. 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MENOMONIE, WISCONSIN AABY FEDERAL SAVINGS Business: 273-4945 True Value Tom` AND LOAN ASSOCIATION Residence: 273-4155 Hardware REALTOR y7 - Car: 792-2732 .i DAR-RAY Realty© 319 EAST GRAND AVENUE Raymond Huppert Authorized PAINTS EAU CLAIRE, WISCONSIN Dealers 207 NORTH BRIDGE STREET 372 WEST MAIN STREET 332 West Main Street 698-2377 CHIPPEWA FALLS, WISCONSIN ELLSWORTH, WISCONSIN Ellsworth, WISCORSIn 54011 Woodville ,FPAHIMt-N1 01 INt)HSIRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <\BOrt X rluMnN Ittl.nnolvs I> IttJx /96l) PRIVATE SEWAGE SYSTEMS DIVISION HUREAU OF PLUMBING dtl\UISUN, WI 63/UI ' I - I CONVENI ZONAL l _1 ALTERN J I V E n 1 I1 Nuu (1I .Ia ti gii,.~I1 I Holding Tank I In-Ground Pressure I Mound C~ ADl]HF SS Oi PENMIT HOl Ur 1 INSPEC rIUN DAi E/ C r _ f( N('II MnR IP is 1 ~ , w -M ULSI.HIeE IF UII I L H/ NT f HUM Pl AN _ - - ' - - REF PT. ELEV C75 hi I Pi I LFv - MI'/MPRsW N,, - - ( "^'w Sa 11ry Pei n~Il Number - - _ - - _7 ,EPTIC TANK/HOLDING TANK' nANUFncTUlieli -UI - - I.I(lUlll(;gPA(;ItY IANKI IET EL( -V TANK (IUTLLT EItV WAHNIN(i LABEL LOCKIPr-,C V J PHOVIDED PHOV C 1~LS Jv V / XIYES I_JNO E ✓I INO - uL DDING - VtNI I]In - VFNTMATL - 1,11 II VJAlr~7 - - (f NUMBER OF +ono PRUPEHiv wFEL HUITDIN(, VEFINT / nl ARM N p -7 I° YLS FEET FROM L.wroUlHrsH I I LINO ( I IYES ~_jNQ L OQT 57 _..__.A 7 ')OSING CHAMBER: _ "nAN r1 Al 'I IIHI H HF DI11Nl 1 If ID CAP ACI I Y I'UMI MfII)I 1 - PUMPISIPHUN MANIIr AC TIIHEH WARNING LABEL - l ocK ING COVER ( / PN ] IUEU PHOV IDEL) v C~At I YES ~__]NO C! YES NO YES L_~NO ,ALLONS PER CYCLE_ - -Nonni n"u(.o"ro ntsoPEnAiIONAL - - - NUMBER OF rRUPIHrv will HUIL I VENT TO rM Sit DII P BETWEEN ) `J S FEET FROM Nr 1 UMP O UN N AND OFF) ! YES I_JNO NEAREST 7S l ~J nlr ~E~ f - - l( IL ABSORPTION SYSTEM Check thl: so11 molsturE It th ~ depth of plowing FORCE L I Ncrrl DIAMI - r11IIIAIn"u MAHKI i; ux(.aveuon. (it soil LHP be lolled 11,C) a wire, construction shall cease until na soil is dry enough to cootlnue,l MAIN -I D ONVENTIONAL SYSTEM: - - NI11 1 11 R I'II'I i '.INr_ tf)VLII - - BED/TRENCH a f!r R]t rIn u us o uiD lN . DIMENSIONS Mnn : w'a` PITPT1, I IlL nFl'II I' 111 I'1 fl 1 i IP( ~DISiR PIPE MnTF.R IAI. NO UISTH NUM PHOPERTV wC L - ING VEN I IwI'IPLL ( Ill I V BER OF PIPES AHOVI I, I 11 t I NO NO T TO FHI.SD FEET FROM a"E Ain INLET - NEAREST _E. - - - --I- VIOUND SYSTEM: - MOUnd site plowed Perpendicular to slope Check the texture of the fill matetlal for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. LINO ;OIL COVERS ~ YFS xiuHf Pk I1MANI NT MnI/K!N ~yj oi6stwvnnoN wL! 1 - - L YES NO LES _ _I NO 1 PIII UVFN IRf Nt.II Ifl 11 1111 I II I/vf R 1111 NC11. HF II _ - NItH II)tt- I1r111 UI rcfl 1111. I(1(,1][I~ SEt(]ED Ml/LC RLD I El /L I_IYES L NO YES ENO YES NO 'RESSURILED DISTRIBUTION SYSTEM: BED/TRENCH Nl D rR"I)L NOFGI,E nrLRAL saAl INr, I,ilAVU Dtvrw HLLUw Plvi-- FILL otrrR AHOVe ci DIMENSIONS 4 i H~ S S L / / ..-~~w+wy-~...~_._. M NII (It 0 pump - M.NII f1ll DIsoi PIP MANY( III MATT H,,AI fJI ,71, DISTR PIPE DISIHIIiIIi I()N PI E MATERIAL tL MARKING III fLLV 11,E flkl L Le vG UIA 1`LEVATIONANU OISTRIBUTION R(~5 L HUI! SI AUNt; 6F,1 LI I L nr1Ha(.1 L INFORMATION, vl~1{y T1 HAi VEHTICAI 1111CORRESPONDS TO APPRovt to Pt YES NO r'LI/MANENTMARKtHS JCTHsTFWAiloN wEi-Ls NUMBER OF F ovERrv f'ILLL2, 1 tDINc FEET.FROM uNI I JNO YES LINO ~ ~ /JD~ I 7/i/ fo2z I y . I L ketch S Side. on taro in county file for audit. reverse Slde P/ SIr_,Nnr>, one 1 ,ILHR SHD 6710 1R. 01/621 - - I -J i c J 38' - y ,r ~ c;.~.am r a W eI i t I y I i ~y I 1 1 r ~ ' I i It 0 U V L L L Jt \L'I s. i t"Ll'\ OWN I:k TOWNSHIP SEC., 1' N - Ri !W AUUItI S`; ST. CRO1_X COUNTY, WISCONSIN. SUh1)IVI:i10N LO1' LOT SIZE PLAN VIEW Uic' CariCea and dimendiona to iueeL_ requirements of 1163 A. VLXYTHING WITHIN 100 FEET OF SYS'1'E:M X di a e o th A Iro - - SCALE: BENCHMARK: (Permanent reference .Point.) Describe: C". Elevation of vertical reference point; , c r Slope at site : SEPT) C 'L'ANK.: Manufacturer; Liquid Capacity ; Number of rings on cover ~6 Tan~C mianhole cover eleva._tion: `lank n'l t. E; Leva t: ion , I ~.L~_. Tank Outlet _ Eievat ion PUMP CHAMBER . MiMLOl IiC t_W_O r : Nunihc of gdi i 1_on6 ~ . WILLW r-r of gill.~ pum_p Set -fur _i# _Cyle_ - _ 0 C Ealloiis; total- Capacity o I ribur io[► 7.1neti al:Ion size. of pun►p u~/---~ .2t; ----head, ~,ta.l Lon per mixtute_ -7 g„ horsepower rangy name of pump and mode J number, ~~r 1' Type of warning cue ce HOLD IN(; TANK, Manul'act:urjr Nuuibf~x ~,f ua1Ions Elevation of iminhole ccver Type ot, warring device SEEPA PIT St/E: _ Number_-o_ f pit: fuet ~iiatneter fee-L liquid d pC l__ seepage pit inlet pipe --elevation bottom of seepage p:1t c:levrit~ri feet SEEPAGE BE'D SIZE; dumber (if lines 3 vidtli ; le thth47 tile depth ` SEEP ACHE 1.'RI'NCH: width lunEth REQUMED r~ ___AREA S BUj_L PERCOLATION RATE INS PE C'T'OR DATED PLUMBER ON JOIE- LICENSE NUMBER-_39_5 3 PL B 67 State and County State Permit # Paz .o Perrnt Application County Penn t # _ for Private Domestic Sewage Systems County !v_ DLNOIES ''~IAff APPROVAL REQUIRED bare Approvt,l Re(;Ulved from State it Required d State Plan I.D. # -3 A. OWNER OF PROPERTY Mailing Address: / Pa. 1 Ph e~- -n e Wv 9 R1 o0r. M. T N sy~ LOCATION Section 10 T N R 7 E _ (or) © Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township R4,yh ✓ee TYPE OF OCCUPANCY -"Cornrnercial` "Industrial "Other (specify) Variance Single family ✓ Duplex_ No of Bedrooms ~r ~7 No. of Persons` SEPTIC TANK CAPACITY - -1-52_QQ Total gallons No. of tanks _ HOLDING TANK CAPACITY 1111111111► Total gallons No. of tanks Prefab c:onerete ✓ Poured in-Place Steel Fiberglass Other (specify) New Installation Replacement A__' Litt Pump Tank or Siphon Chamber?_ Total gallons Prefab concrete ✓ Poured-in Pl.:,:e ----,Other (Specify)____ i EFFLUENT DISPOSAL SYSTEM Percolation Rate - .-Total Absorb ! tt. New -_-_-Rcplacement_,✓ Alternate (Specify) ,I-y7~ Seepage Trench- _ No. of Linc.I Fk width epth _l ile depth ot=_. _ Seepage bed: -•~_ZLength.._ c ( F 1 No. of Tnn~,,, Width dor _,iLAepth_-_W- file depth (top)-_ No. of Lines--# Seepage di a tter Liquid Dep th No. of Seepage 1( Pits__ - -*Percent slope of land b v O 57 Distance from critical slope , IATER SUPPLY: Private >4 Joint F J Community L I Municipal twneis name as listed on EH 115 if other than present owner. - - I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, - Nisconsin Administrauve Code, and that I have sited the effluent disposal system from the EH-115 prepared uy the Certified Soil Tester, G' `DAME C.S ,ot S. T _,;Mli ~ d~ and other information )htained 11011 F wne builder 1. Plumber 's Signature `lumber's Address + 1 R r,[ a r: d o N1P/ PRSW J'sl Phone # PLAN VIEW Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- l Lion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. It well has not been drilled please indicate. ------X03-~-~--"°-_-- r - o 0 0 I t / to,,,4o 100, " 4 rt ~C q V u v-, Z Nc S u~ Qo , Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE NL Y PC 1 to of Application Fees Paid: State Q ! County Date emit Issued/H'efetted (date) n ~ Issuing Agent Name hection Ye, k_No State Valid# Date Recd count y white copy) 3. owner (green Copy) DIVISION OF HEAL 111 P O tsi)X.:309, MADISON. WI 5:1701 rF SENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDI, DIVISION LABO H° n- - PERCOLATION TESTS (115) p:©r X 7969 HUMAN RELATIONS MADISON;.IN1_ 3707 C LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO".:BLK. NO:: SUBDIVIS - 1/ . ?/a /T. -N/R E (or)- , COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE r NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILE R T O S: R LA I. T S: ❑Residence ❑New Replace If RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) DS E]U S ❑U E]S ❑U ❑S DU bS ❑U . If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL 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. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B / - B- B z; B ` B- / . PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P - ~c /'7 P- -r 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. • f~ SYSTEM ELEVATION - .7 U I N' IN 11 ( ' X r• - ~--,.<-mac, i r _ r r- i, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified 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): CST SIGNATURE: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DI LHR-SBD-6395 IN. 03/81) W~ all O 1 S_n 3 k`~ mil!".•~'` d j Pis 1URPHY r~ V = 12799` RIVER FALLS wisc, 8102499 . 1r _m A PR 2 1982 e cl p ~IIrN , y IB.I ~d I .x,31 .P r;•~4 iry ~ ~rv~°'~ {~Ib. e r CIs I b~ ~ CO, j. pal f~ 1~. i~~{•,? •.a ' ~ V a c b aA~1 r "~I ~ kI t t d~ ~ I F k a N ' S ,vF ~ I ii F s ` y f ~f p t i r F a I I TLS\VJII k I 1 I ~ ~ .1 ~ !I y 1r ~ ,q ~n iI I ! it < 9 i I ~ ~ ~~11 tIy ! 11111, 1' ,q ti. 1 1a~y.b. 10,3 498 w z S y 1082 I N. y'. cc~~ N , f r TOP J, - AT NAJ A : r i 1 NO V 3' OR 102 ~ It 1 , ,'S, r~ ~ YYY C 5 r l yt ti Yt, t IU- 1 F4 d j~ Y: F"~. / Lyl~ ~ r y. i K{ •t a y ~ 4~ *f v L6 a ~ a ~ 5 Jf a~ r 1..1 5555 1' i i f Y d i I `=?C7 l; ly ! 4 T _ t\`l~~a lAa~..C.d..._L- sj Qt522=v^ op v~ E T t-t :.5 j -!f '-'"'y^O1.i/.'~/ ~o~ .F~.i.!,"T'.2_.6.+,._. ?,A X, 4Nk rC?t_. 1r`: s i ~C i. a i 9~y G a 1 ly5 ~>~i'"r='~. ,._.1 _ Yom" l C' y i . Z .C- L, !',317 ~i V Z J+ 4-C 2"tr'ii 'S"-rc-`~ . - r". F,~-.a~; fv-C?.t.-.,`"ski?np~, =:5~ '"~.Z - l APR 2 11,082 L MR1,NhC, SEi7r F I-) r r ~ ,a i t L` VFW 8, ~k1J IN LD ti Y Colt ~ Ax- Id `e. i f„°l ~ . y r=te a w.. J'~,..3 ~t i i.a I +>h~ ~ .i C ~ "AA x..9 v~~ C}I"~", 3 r C_ L t f... A F, e,: M . t... e r , ! f f 6 " ! r p t~ ~ l s4 , ~ ] ( pp 1f b 1 h n 6 d ,per ! V i ..,.y Y O. 51 lh f. C ~ l .71 R 11 d Y fF a~ a u ; a , r t - ~l J ~ ST. CROI X COUNTY W I S C O N S I N 7ONING Of F ICE 196 ??;39 r-1 rj HAMMOND, WI 54015 July 14, 1961 Division of Safety and liui-l(1i-nh,s Bureau of Plumbing P.O. Box 7969 Madison, W1 53707 Dear Sir: An on site investi);at. i_On (or the Paul 'Phernet: ton property located at. the W4 of r lie SW'i. Sect:lon 10, 1'28N-R1.7W, Rush River 't'ownship in St- Croix County, revealed suitable soils at a doi~th cif- 49incljes, below which seasonable high ground water was no ted . This site should hi- sii i t rih I c l or ;ti) in-groliml pre';s irt. system. Should you have any (lees t ions , 1) 1 (-rise Cee l Ire(- t <I contact r_h.is o.ffi.c•e- Yours truly, Thomas C. Nelson Assistant toning 7ldmi ni s t-r.ator- TCN:sl 6/17/80 WISCONSIN DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING, PLATTING & FIRE PROTECTION POST OFFICE BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for in A ~ternative Private Sewage System In the County of ro; Location SQL 1/4 SW 1/4 S 10 T 28 N, R 17 X)Vt6iO W Town or Municipality Rush River Street Address R.R. 1 Hammond, W1 54015 Lot. No. Block Subdivision Landowner's Name: __Yul Phernetton The application for this site is to serve a: ❑ new construction use., © replacement system use. If this is a NEW CONSTRUCTION USE, the alternative private sewage system is to be included as: part of the 3%/5% limitation. This is number of the applications made through this office. ❑ one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. ❑ an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. L_J a lot that meets the site criteria for a conventional private sewage system. If this a REPLACEMENT SYSTEM USE, the mound is replacing: n❑ a failing conventional soil absorption system. a holding tank that was installed and in use prior to February l; 1980. ❑ a privy that was installed and in use prior to February 1, 1980. 1 certify that the above information is true and accurate to the best o .my- aowjgdge. Name ---L}~vr3o,S e ,AtISon Sign - Title ~ ,.~.70 IN„_. -'Pln, Date August 11, 1981 DILHR-SBD- 6158 (11.7/80) 97 ata >I 'And Return Upper n tate of Wisconsin DIVISON OF HEALTH Portion Of I This C form With ECTION OF PLUMBING ,y CO, A IRE PROTECTION SYSTEMS Any Return Correspondence ZONING IL ADDRESS: P.O. BOX 309 , Off~re~G AD SON, WISCONSIN 53701 608-266-3815 DATE: PROJECT: SWz4, Sec * of Rush 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 plan review fee required is $ ❑ Plan accepted for review. Fee received is $ Fee is being returned because of ❑ Overpayment ❑ Underpayment. Providing one of the two catagories above is checked, remit correct fee in one payment. ❑ No fee has been remitted. Plans submitted with no fees will be held in abeyance. ❑ Plans being returned. ❑ Additional information required. SEE BELOW. 1. Plan Submission ❑ Additional information shall be submitted in triplicate unless specifically noted. ❑ Plans not clear, legible or permanent. ❑ All information submitted shall be signed, sealed or stamped in accord with Section H 62.25(2)(a) Wisconsin Administrative Code. ❑ Affidavit enclosed. 11. Alternate sewage Disposal Systems (Mound Systems) ❑ PLB 108 (Application for use of an alternate system). ❑ County onsite required (1 copy). ❑ Design calculations for pressurized distribution ❑ Cross section of mound. ❑ Pipe lateral layout. ❑ Plan view of alternate. 111. Private Sewage Disposal Systems ❑ Ground slope with 2' contours in entire area of soil absorption system extending 25' on all sides. ❑ Elevation of permanent reference point (benchmark). ❑ Location of area suitable for replacement system - provide soil test data. ❑ Plot plan showing lot size and all lateral distances from sewage disposal system or holding tank to bldgs, lot lines, well, watercourse, etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. ❑ Construction detail and cross-section of soil absorption system. ❑ Soil boring and percolation test on EH 115 completed by certifiedsoil tester (1 copy). ❑ Complete data relative to anticipated use of bldg. ❑ 3 copies of PLB 60 enclosed. ❑ Deed restriction required (1 copy). IV. Holding Tanks ❑ Profile of holding tank I❑ Holding tank agreement signed by owner and local unit of government (sample enclosed). ❑ Reason for installing holding tank soil test or statement from county (1 copy). V. Lift Pump ❑ Calculations for total lift pump discharge, head and gallons pumped per cycle. J Size, length & depth of force main. Detail & model of pump or automatic siphons including size, pump curves, drawdown and average flow rate GPM. Cross section of lift pump tank showing pump(s) or siphon(s). V;.:Sk,~sterns In Fi!! (Fil! must be placed prior to plan submission) 1__l Total a:ea filled (fill to extend 20' beyond edge of french before side slope begin). Depth and type of fill. L_ Copy of onsite report by county or district plumbing supervisor. Length of time fill has been in place.