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HomeMy WebLinkAbout040-1201-95-000 c d ~1 , ° cc 3 ~ G _ ~ Ct # CD A n m O M (NA O O (O C E m A • C=D 7 3 O fD W~ N O ~ CD c) CC) 0 v c- Z dZ ~ N N N ~►i lAl N o ~ CD 51 W N m O C) CD -a 1 0 O W 'con 0 0 0 7 (~D a O (n N 3 O p v O r C) 3 N 7 p 0 d (D w (o i O° CD C N C Oa O O W C C~. ~ N O 3 f1' ~ O ~ 1~1 CD ~ Q I N N Q ~ V Cr w O S H V O A A= N^ Q !V co co o ul 7:7 ~vv0 d h, 411 ~OZ W O Z O Cn D G G G z 0 0 ~v N v1 d m N N N a. c A a00 a CD CD N N m z m z 0 0 CL Z) y z N Ql CD w Q s CD (n 0 o i-ry I m w c N' 1 S C O Q CXi r 1 W N _ G~ O Q n 3 7 1 (A p N A Z C n o n a A C) o n Z N ~ -I W v m W co 4 fV CL z A 3 m co z ~O CD A W Q m a 0 3 v c o' o 0 CD N N a I a I ~ I a 0 I ~ N O O I a Q o b N ~Q o 0 m zz A CD ~ y ~ ~l Form - S T C - 104 AS BUILT SANITARY SYSTEM Ri~PORT ~~i- ~.,,~t ~r~~~T~.✓ _i~('a.~ TOWNSHIP~~~ f SEC. 1' N-R W OWNER ri - - - - ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of EI 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM l~ ~I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ,Z,~ Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: = Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank ;Cnlet Elevation: jTank Outlet Elevation: Numbe;- of feet from nearest Road: Front,Q Side, 0 0 Rear, /1,1- feet From nearest property line Front,OSide,~Rear, ) feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE;REVERSE SIDE PUMP CHAMBER Manufacturer: 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, 0Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include yistances on plot plan). SOIL ABSORBTION 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, , Rear , Ft Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid 0-6'pth: Bottom of seepage pit elevation: Arm 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 ringsiused: Elevation of boutom of tank: Elevation inlet: Number of feet from nearest property line: J Front, O Side, O Rear, O Ft. ' Number of feet from well: Number of feet from building: _ j~ Number of feet from nearest road: AI-arm Manufacturer: Inspector: Dated: Plumber on job: ~i License Number: jji~/ 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOFs & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. B%iX?969 BUREAU OF PLUMBING HADISON, WI 53707 ❑CONVENTIONAL ❑ALTERNATIVE Sate Plan I.D. Number: (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPEC ON DATE. _ Randy StenzgaaAd 70l - 11 h ST., Hud~an, W1 54016 BENCH MARK (Permane,t reference point) DESCRIBE IF DIFFERENT FROM PLAN. T. ELEV.: CST REF. PT. ELEV.' NE SE, Sect. d, T28N-R19W, Town aj Tnoy, Lot#10, Nandic Heights Name of Plumber. MP/MPRSW No.. County Sanitary Permit Number. Gary Steet 3294 S Ctcoix 49432 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET EV.. JW RNING LABEL LOCKING COV C~eL "✓~~J ~ PR V ED PROV ED Gr` 5- YES ❑NO NO BEDDING. VENT DIA. VENT MATL. HIGH WAT R NUMBER OF ROAD: JPROPERT( WELL / JB . WENT TO FRESH C / ALARM FEET FROM LINE AIR INLET: ❑YES O C ❑Y O NEAREST ill. fa I 1_711 1 _-7 DOSING CHAMBER: MANUFACTUR R BEDDING. LIQUID CAPACITY PUMP MODEL PUMP./ IP MANUFACTLIv WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ❑NO R ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE; PUMP AND CONTROLS OPERAT40NAL. UMBE PROPERTY WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN ! FE OM NE AIR INLET PUMP ON AND OFF) ❑YES NO AR T SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of pl g LENC,TH.= DIAMETER MATERIAL AND MARKING or excavation. (lf 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 SPACING COVER INSIDE DIA SPITS LIQUID BED/TRENCH THEN Es M IAL: PIT DEPTH DIMENSIONS f ~2 I,s , GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DI R NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPL 5.4 ABOVE C ER ELE VB ;fy~ET ELEV. END PIPES' LINE AIR INLET. FEET FROM NEAREST 10 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- ❑YES ❑NO meets the criteria for medium sand. IONS MEASURED. SOIL COVER TEXTURE ✓ PERMANENT' MARKERS OBSERVATION WELLS j ❑NO ❑YES ❑NO DEPTH OVER TRENCH.BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED ZDED MULCHED CENTER EDGES u YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACIN IGRAj~E_ DEPTH~BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES i DIMENSIONS ¢ MANIFOLD PUMP MANIFOLD DISTR. PIPE M (FOLD MATERIAL. NO. DI R. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.'. ELEV.. DIA. ELEV.' PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COR CTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED I PLANS ❑ S ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF LOPERTV WELL BUILDING C 1• FEET FROM INE ❑YES ❑NO ❑YES ❑NO NEAREST C4 Z \ 7~s E Q C~r610 Sketch System on Retain in county file for audit. Reverse Side. lG SIGN E. j /j/J/1 TIT DILHR SBD 6710 (R. 01/82) o F wiscons'n APPLICATION FOR SANITARY PERMIT ~ DILHR `6;-0/~000NTY ~OEPRRTTT1EnT OF (PLB 67) UNIFORM SANITARY PERMIT # w E InOUSTRV, LRSOR& HUMRn RELRTIOnS ry1 / 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 P ERTY] OWNER MAILING ADDRESS PROPERTY LOCATION CtT-h: C 1 /45 C 1 /4, S V6, N, R Z\ (Or) VII TOWN OF F: _/~-c ~ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 2 1 or 2 Family Number of Bedrooms: ~ ❑ Public (Specify): THIS PERMIT IS FOR A: X 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 X 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 Lift Pump Tank/Siphon Chamber Holding Tank capacity manufacturer: 5 c' 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 Capacit j Lift Pump on Chamber Mwru~aacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): / 5 ~5 c"1[ 'C Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name f Plumber (Print): Signature: MPRSW No.: Phone Number: 5 4 ? 1 ~/5 1 ~ zc2~ Plumber's A dress: ° Name of Designer: z COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Disapproved Y Approved ❑ Owner Given Initial bt T 7 ~(J 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. ForIII - S L' C 100 i Owner of Property e Location of Property ,V Section <2-,T_s-N R_L_~_W Township_ Mailing Address '7a l~ c1 "45 Subdivision Name_ j/1jrd, c f/e, J~ h 2` Lot Number Ip Previous Owner of PropertyO'Aa ,/p CU- Total Size of Parcelj.j 5 Date Parcel Was Created_ Oct jq j y 9 _ r - Are all corners identifiable? - Yes No Include with this application one of the following; Certified Survey Map Deed .Land Contract, or .Other iregal Document which describes the property PROPERTY OWNER CERTIFICATION 1 (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 dead recorded in the Office of the County Register of Deeds as Document No.-, S 6 -H ; and that I (we) own the pro presently posed 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 twYN4R S14NAT E OF CO-OWNER (IF APPLICAe ) DATE SIGNED DATE SIGNED DINGS DEPARTMFNTOF REPORT ON SOIL BORINGS AND /f7s"''G,(~ DI ISION INDUSTF~Y, ,qy UMA AND PERCOLATION TESTS (115) t `r 7969 HL1fVIAN RELATIONS \ / .~}t ~ A~N, 3707 (H63.09(1) & Chapter 145.045) c 4 LOCATION: SECTION: TOWNSHIP/" - tf/y: LOT NO.:BLK. NO.: IVISI NAME: 15 C '/4 C ~/4 AT S NCR (or) W ~f 4-s COUNTY: °S/BUYER'S NAME: MAILING ADD SS: ( ` / rJ 1 of >,54Z 6 4r 3" l3foS / Cr y G ';~GL /JC7 , . / USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER O LATION TESTS: Residence J CkNew ❑Replace I Z ~ _ 3 _ z J ti3 - 8 3 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: W-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) aS ❑U OS ❑UI OS ❑U ❑S ©U [IS CCU If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.1163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ~£S rn/+(i PROFILE DESCRIPTIONS P~ BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER Dexfl_~, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) P 13- / z` 63 z l✓ 7 ~v 1 z c~ r B- L7 ~a 0J0 NC)/0 ~0 C3n,~. 3j t3 L.S, 0 00 S8 B- e o o c) N c> nJ E _ X 7 fl . G . 3 9 4-35 6-61 /L) 917 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 6 AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PERINCH P u / P 1z Iii J~ 41 3 P- N ca 3 % to < 3 P- P-2-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 ~ 7 5 4 6-s 1 o r 12 /47 A.5 men4S `I0°t (,-m bo 6 s+. J„p-f I-, n .._.r JS` ogra"D 13- r w o 13-3 ®a+~ P- 3 lsi'13- it Yr~ A E ; _ o {,,ofSE K~ l0a 13m= -f 6vf 5,0' qt I, the undersigned, hereby certify that the soil tests 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): (TESTS WERE COMPLETED ON: '9ESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): riC~ &11627 ✓ra~~Clrt Z_ z 9 x16 ~oZao CST SIGNATUR ginal and one copy to Local Authority, Property Owner and Soil Tester. h. 02/821 ounqq A! Nit, Ain"I soul l~rpf i , . Of f pi lEms. E ,,dfTel xi~v,r FF1F , c xx OUT J ;~NS; L.~l~iE~s s- ~s ~ .w ARE -3;.~_ RULED ~„-_~F=....` i.). ~ Kull ...f~^ATIa e N `e xi. z...EASE .-f. v s <~z. 9s „3~~r ~ , , q p%50ei. 4_d f?~,E.t ,r-1.tG+~s and na YtoE0'C4nti the At Q7T; QI <i a_.., ,nA „x vial, . ow kmC.E-r,C2 f ,.rJ,i to Wo 4 jat'~t,owr4. 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