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HomeMy WebLinkAbout040-1000-20-000 n (n O v n d _1 O ~p CD ~ ~ ~ (D 1 O 0 co 71 -P~ O O < N O 3 yy r 1 ° SL CD C) (D (n * `O o S N N n W N O 1 3 O 7 10 0 (D (D -a CD (n N C: y ° l\ 7 in O C N o o (D U a C I~ N N i53 N N O O O .Z7 O C', O (D O N CL lz ~z (D N a? N .Or. 6 h• In n N O Z O O O K 3 (n <n N (n D v 3 c v w g 0 O 0 zi o v v rn 'U n I m m (D N 3... W (D N Q 7 ? Z I O C -1 Z O O n O j 77* O O n O. S N (D ~ O y y (D C C N CD w m n 7 _ n N (p ICI 1 cn Z D p Z N O U) OC n' 7 A Z O v n ~ 7 I p 7 Z N 00 m CO O c? Z R o Z 3 m y CD (D A W N O O (n ~ (n ill N N O. d N Q N _ n 3 (D N (n o. C 'I 3~O (D v 7 T CL O W 7 O X O Z 4 (D (D O ry-. N O C C)_ m 7 _ cn ? y O FD O a) "n cp 271 O CD ~G (D p (n ,A (D n 3 N < v 3 3 N m N OO~-n (O N N N N (CD 7 (D N 77 O ti ~ O y (D 0 n 3 (D y O~ O a (D O O 6 N ya O O- 'w r • Form- S T C - 10 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ~ SEC. T IA N-R 7 ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH,R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S SIC _ lJ~ ~ ;i OF ,`fi`r., r-'~u Iu T y t f yr' •1 ~ t I ' ~ ' e i i r I ~ i i ~ 1 U INDICATE NORTH ARROW r~-~~.,..::✓ r ~y _ . ~.e,.:.e ewe ~ BENCHMARK: Describe the vertical reference point used', Elevation of vertical reference point: c. Proposed slope at site: SEPTIC TANK: Manufacturer: ri Liquid Capacity: ezfcu Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side, Rear, O feet From nearest property line Front, 0Side, 0Rear, 0 feet Number of feet from: well z~ building: 'IS' M nclude this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE t PUMP CHAMBER r Manufacturer: i Liquid Capacity: 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, O 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: 'j Lenith: - V Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, (D Rear,0 Ft. LfC: Number of feet from well: G . Number of feet from building: -,,,,4 E (Include distances on plot plan). SEEPAGE PIT I~ Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: >'ir 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: • - 141 r Dated: Plumber on job: ~v' V' License Number: 2 3/84:mj LABORR& & HUMAN OF INDUSTRY, LABO / INSPECTION REPORT FOR SAFETY & BUILDINGS RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS / DIVISION MADISON, W`L 53707 BUREAU OF PLUMBING / Xk] CONVENTIONAL OALTERNATIVE State Plan I.D. Number f~ E Holding Tank E In-Ground Pressure D Mound (It a-god) NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION AT Dennis Rivard Hudson, WI /O -_?n BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: 7CSTREF. PT. ELE V. NE NE, Section 1, T28N-R19W, Town of Troy Name of Plumber. MP/MPHsW No.. ['"'y. Sanitary Permit Number: Roger Timm 3224 St. Croix 58916 SEPTIC TANK/HOLDING TANK: MANUFACTURER'. LIQUID CAPACITY: TANK tINLETELEV TANK OUTLET ELEV.WARNING LABEL LOCKING COVER PROVIDED: PROVIDED It' NO EYEBEDDING. VENT DIA.VENT MAT .HIGH WATER NUMBER ADWELLBUILDINGVALARM FEET FRLINEIYES NO DYES NO NEARESZ~ Ivy C DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ENO EYES ENO EYES ENO GALLONS PER CYCLE: PUMP ANO CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE I AIR INLET PUMP ON AND OFF) EYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NC',rH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF DISTR. PIPE ACING COVER BED/TRENCH TRENCHES. V b ^ INSIDE DIA -PITS LIQUID IAL DIMENSIONS S MAT. k. PIT DEPTH GRAVEL DEPTH FILL DEPTH UISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. PR OPERTV W ELL. BUILDING. VENT TO FRESH BF LOW PIPES ABOVEyCQVER ELEV INLET ELEV. END' 9 NUMBER OF PIPE FEET FROM LI'l 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- EYES ENO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DEPTH OVER TRENCH :'BED DEPTH OVER TRENCH:'BED - YES NO EYES ENO CENTER DEPTH OF TOPSOIL SODDED SEED MULCHED. EDGES. DYE ENO YES ENO EYES ENO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH T~10 -OF RENCHES LATERAL SPACING GRAVEL DEPTH ELOW IPF FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIA NO. D TR. DIST' . P DISTRIBUTION PIPE MATERIAL & MARKING. ELEV. ELEV.. DIA ELEV. PIPES DIA. ; ELEVATION AND [DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER M TERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES ENO EYES ENO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE ~U OYES ENO DYES NO NEAREST ? t 7 17 Sketch System on Retail county file for audit. Reverse Side. SIGNATURE. TITLE. y DILHR SBD 6710 (R. 01/82) r W05consln APPLICATION FOR SANITARY PERMIT ~ DILHR oEeRRT (PLB 67) d COUNTY IEnT OF UNIFORM SANITARY PERMIT # Ir10USTAV, LABOR 6 HUmRn RELRTIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS / PROPERTY LOCATION CITY: VILLAGE: /4 /4, S ✓ , T , N, R.'Y (ar)`W. towN or LOT N/UMBER BLOCK NUMBER SUBDIVISION AME NEAREST ROAD, LA.gE OR LANDMARK - STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED U- 1 or 2 Family Number of Bedrooms: ~1 Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair X Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed Q 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- , 1- Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic a Gallons Tanks Concrete Constructed Septic Tank Capacity $o-; Lift Pump Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ~ Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP/ly{EiLW No.: Phone Number: Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Disapproved 01 / v L ~ Owner Given Initial j 1 jJ L: 4 _2 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. APPLICATION I-'OR SANLTARY PE MIT S 1, C 10() Th i.:. uppI i cnC ion I or1❑ ir; to b(- compl ut d iu 1 u 11 and .5igncd by the owner(s) of tli~ property being deve.oped. Auy inadequaeieS will only result in delays of the peril-: 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 ~,oLd and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owuor, oof Property Location of Property 0I/ ~4 -4, Section t N - I, W _jQ Township Mail i_ng Address r - L/ Subdivision Name Lot Number. f'r;~vious 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) ? Yea - T No Volume and Page Number as recorded with the Reg ister of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty lleed Z. Land Cmit_t.tct i. Ot hey rcr~ urd l ags f it ted with tht^ R( glt;ter of l l (ice ]n <rddition, it certified survey, if available, would be helpful so as to avoid delays o1 the reviewing process;. If the deed description reterences to a Certified Survey Map, the the Certified Survey Map shall. also be required. PROPERTY OWNER CERTIFICATION I (We) cw,iby tGta-t a"-"e htatementS on th.c,, (ju/cm '111 t"!- w tote my (OWL) hnowtedge; that 1 (we.) am (ahe) the ownm (,s) o{ the pnope.,z.ty de.~e,,ciled ('n ,this cvi~jonxncti-un 4onm, by vi.A,tile of~ a waAAanty deed ~Leeorcde-d in the 0~6~,ee o6 tile County Registm oA Deeds a,~ Doe.ument No. _ % and that 1 (we.) pne'sent.ey own the_ p"copoaed 64'.te {o"c the .sewage di6pv6at system (on I (we.) have obtained an eabemen , to h.un with the above_ deaeni-bed p-zopeAty, bon the c--rust aiction u' said .~ystem, awd t6'te bane ha„ b,en dicey necon_ded 61 -tGte 0~(('C(l uAy .the Cuunt~l Req.6 ten uf~ Ve-(!-tas, a6 Doe.u.,rw.r1.t No. ) . 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