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Home My WebLink About020-1136-40-000 d • O cn o m do -a o O y C 7 7 n 3 ~ `G Q C M i d I i 3 co C]~l • I O O Z A C O ~N 41 U7 O V O Q N iO FH 3 3 cn Z n N W 'a NO w 0 O O (n OCY) CL O 1 N O = Q m A C 3 19 m A O o !i N N 1 O O O fV Cn x n td y m^_ c cn I W G F N~ a o c o (D (a N(n a a v Li w cn T W CD I rt o N o •cJ c d c o o 00 p' p fy rj m 3 O v, t-' FD- rt 0 (D W w W co a N p c W H W Cl) w w 2 Q !J H v Z N. 00 ' co oZ O O O • y h o N rn ry -4 -1 ~ A r-3 . to to cn o cn 0 ° Co v N o F rr H Z m d a rn cD _ (D ~ r~ Z 3 m m g D I Z n 3 a _ p F- r o Z W Z c D CD 0 a Q-3 oc fD m m !ti• W (1 'OO N • m 'a (a N [v c N m O w m a Z H O N O A Z c :3 1 $ v a j' (Zj O Z N O W CD m (C) CL Z 3 xo _ A G Z 3 C cCfl (L y z CD < < O A ~ ' ? p7 O Q _ C 77,:2 2~ 7 o N o G X m z 'a ? O O C3) 7 CD co Cr N CL N fi 0 A N N vC CD b O N N y l O N ~ W N N OO f7 I A O ~O O b O b O O ~ cn O a ~ ST. CROIX COUNTY WISCONSIN n, Ev. xunnrn■„,..d ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 771 (715) 386-4680 11, ~ y r March 29, 1995` Mr. Paul R. Nelson Edina Realty 400 South Second Street Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for Residence Located at 415 Valley View, Hudson, Wisconsin Dear Mr. Nelson: Enclosed is the original test results from SERCO Laboratories for water (VOC) inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, ° ~C Mary J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 50876 PAGE 1 of 3 03/28/95 St. Croix County Zoning DATE COLLECTED: 03/13/95 1101 Carmichael DATE RECEIVED: 03/14/95 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins CLIENT'S ID: Sand St Rd .a..._? SERCO SAMPLE NO : 2 7 3 7 5 SAMPLE DESCRIPTION: Sand St Rd ANALYSIS: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - '•j !3 v! Benzene, ug/L <1.0 Bromobenzene u L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 l= -tif - Bromoform,, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. 1 ice` 9 1, SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 50876 PAGE 2 of 3 03/28/95 SERCO SAMPLE NO: 27375 SAMPLE DESCRIPTION: Sand St Rd ANALYSIS: 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <2.0 1,1-Dichloroethane, ug/L <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. 7 SERCO Laboratories 1931 West County Road C2. St. Paul, Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 50876 PAGE 3 of 3 03/28/95 SERCO SAMPLE NO: 27375 SAMPLE DESCRIPTION: Sand St Rd ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L <0.4 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) Vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 This sample's analytical results are below the U.S. EPA's SDWA maximum contaminant level of 1/30/90 for those requested compounds which are also on the SDWA MCL list. There was a small amount of head space in both vials sent for analysis. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Carol A. Davy Project Manager < means "not detected at this level". 1 mg = 1000 ug. V tea.,. i ST. CROIX COUNTY WISCONSIN 'woo ZONING OFFICE ~IIngo III lip _""""b ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 540 1 6-771 0 (715) 386-4680 March 20, 1995 Mr. Paul R. Nelson Edina Realty 400 South Second Street Hudson, WI 54016 RE: Water Results for Bob Sandstrom Address: 415 Valley View, Hudson, Wisconsin Dear Mr. Nelson: Enclosed is the original test results from Commercial Testing Laboratory, Inc. for water inspection of the above property. If you have any questions regarding these results, please do not hesitate in contacting our office. Sincerely, Mary Jenki s Assistant Zoning Administrator db Enclosure i COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX-715-962-4030 KPORT DATE'. 3/16, CARMICHAEL ROAN W7~ ATIOW 415 Vat►ey ECTOR2 M. Jenk i ns COLLECTED 3-13....95 COLLECTED. 2:00pm 'j 'E OF SAWLE. N l tcnk-T gas: > t G O' ..EDi22i011 i 1-11\ D~ CC • 7ATIONS Bacter i a-,' 5 pp. ve 14 U. oF,~ DEGENOf~r O ~ L >it d O v A r dam, 5 PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY WISCONSIN _ ZONING OFFICE ~0 r xn~~~d A MINN ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 March 13, 1995 Mr. Paul R. Nelson Edina Realty 400 South Second Street Hudson, Wisconsin 54016 RE: Septic Inspection for Bob Sandstrom Address: 415 Valley View Road, Hudson, Wisconsin Dear Mr. Nelson: An inspection of the septic system for Bob Sandstrom located at 415 Valley View Road, Hudson, Wisconsin, was conducted today, March 13, 1995. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Also, water samples were taken. Once we receive the results we will forward the same on to you. Should you have any questions in the meantime, please do not hesitate in contacting this office. Sincerely, Mary J. Jenkins Assistant Zoning Administrator mz ST. CROIX COUNTY V WISCONSIN ZONING OFFICE h IINVRIIa "_"6•y ST. CROIX COUNTY GOVERNMENT CENTER ^ V 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 I. SEPTIC INSPECTION / WATER TEST REQUEST FORM A' Please specify desired test(s) & remit appropriate fee with J'? application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make C~ arrangements with this office to insure that entry can be gained. d f: vy ~Ff Water (VOCIs) $185.00 ❑ Septic $50.00 r, 13/Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: d~ S~QN~STIRoM Requested by: c cw-r/ Address: VA1,ury_ VEhv-3 Address: llvim s. J u0saN ONT. ZIPIE, JA "q ZIPS-/aim Telephone N°: Telephone N°: (-7I5') 3 5 3~ Property address (Fire NO & Street) : y~S I/'pcc~y Vc~ >~dAp L,OCatlOll:5 S'w Sec. T 11 N, R-2 W, Town of NUilti `Realty firm: Eb7VA Lock Box Combo: /U F~• Closing Date: q- /a-cIS J TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: k- t'' ~ ''A' Is the dwelling currently occupied? G Yes ❑ No If vacant, date last occupied: Age of septic system: Septic tank last pumped by: Date: 1 Previous Owner' s Name (s) i Z - i Have any of the following been observed? ❑Y -aN Slow drainage from house. ❑Y IAN Sewage Back-up into dwelling. ❑Y .LAN Sewage discharge to ground surface or road ditch. ❑Y ON Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. I OWNERS SIGNATURE: , per, DATE: 1/94 • ~ i' i ~ ~ ~ 1~ J ` ~ ~ ~ . ~ , f .y I f , ~ ~ Parcel 020-1136-40-000 12/13/2005 08:10 AM PAGE 1 OF 1 Alt. Parcel 20.29.19.674 020 - TOWN OF HUDSON 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 - YURK, MICHAEL J & BECKY W MICHAEL J & BECKY W YURK 415 VALLEY VIEW RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 415 VALLEYVIEW RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.500 Plat: 2626-WILLOW RIDGE ADDITION SEC 20 T29N R19W WILLOW RIDGE ADD LOT 65 Block/Condo Bldg: LOT 65 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1117/117 WD 07/23/1997 803/436 2005 SUMMARY Bill Fair Market Value: Assessed with: 92546 229,500 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.500 65,000 169,100 234,100 NO 05 Totals for 2005: General Property 1.500 65,000 169,100 234,100 Woodland 0.000 0 0 Totals for 2004: General Property 1.500 33,500 164,600 198,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 111 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC.,Vtv-TL<;JN-R 'W ,✓V /t, L J,t'~c~~, ~ ADDRESS ~Oy/1vt~ //~iNni. ST. CROIX COUNTY, WISCONSIN. t ~~ts''t3/a C LOTS LOT SIZE SUBDIVISION PLAN VIEW Distances and dimensions to meet requirements of H63 THING WITHIN 100 FEET OF SYSTEM -SHOW i 4D N +b 6 R ,r too Z;9 j AN .t fig I di a e o th Arrow I - c" C L v BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: 0 d Slope at site: DU SEPTIC TANK: Manufacturer: £r`~/4- Liquid Capacity: Number of rings on cover : O Tan manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation. PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle gallons; total capacity o distribution lines gallon: size oT pump head; gallon per minute horsepower_ bran name of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: um 1:21 o pits eet iameter feet liquid depth seepage pit in et pipe-elevation bottom of seepage pit evation feet. SEEPAGE BED SIZE: number of lines wi th leiigth~tile depth SEEPAGE TRENCH: width length PERCOLATION RATE _ AREA REQUIRED_ RE UILT / INSP _ DATED PL BER ON JOB LICENSE NUMBER uo/N ;ER TEST ~'~,v~/Tic ws " S eWv , 3 r, -3 " lWe3 T DEPARTNFENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, p DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADIS ON WI 3707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: mw 1/ 1/ 2,0 /T29 N/R 19 E (ar H Up,SaN !or Willow RA*1r0 COUNTY: * OWNER'S/BUYER'S NAME: MAILING ADDRESS: Aees Co- Sf •CiarK ,6v;~aE,p C~~G ~ho•~r sQ.J MOP I ✓~'~iV/V ~ W,9kdi~ vvso.,J, c~,s USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ? if/L New ❑Replace 441~ ' q ~3- j", i? j063 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) DA~ ~S ❑U OS ❑U ZS ❑U [:IS DU [IS X U W4;AA14D If Percolation Tests are NOT required DESIGN RATE: 1y3 Syt. /-j- If any portion of the tested area is in the 7,y oQ 3 /3cyRt o~ S A5- fox s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: x PROFILE DESCRIPTIONS y /.~uP,P~OMS 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.) „RAT; F, FV . B ~cu1 ~c 2- l~ /O F 11"1341.51-, ~'L/•Av. SL, 167 Fake -134 Uej B- J 1 ,5/ /k" 130 Gogh, y P, -/3a1. dP~cy B- >~13W 9 Al. ;7,0 B- D4,rt, i,v 4'e' PERCOLATION TESTS TEST DEPTH WATER IN LE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERS LLING INTERVAL-MIN. PERIODI PERIOD2 PERIOD3 PERINCH U• 7 06 G 012 i j) p_ p- L 3.o )~Or t=au a.-4 L < / P- y,e ` I i P- 41 '7 3, Z 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. ii5e 1WE FT' I-L) SYSTEM ELEVATION Kok ME-* 3-Y5 l-lpa/.ur I 4-- - f I V' /ck'rAfjC __,F'~~EE.!>cE~Dior • %5 fad ~ ~R ~ ~r 73&~ 5;rAn'1p, ouf i /00, 0 z 70 03' i , w , 0/ ; a/ - _ x 5 ?O' A, 3P yj y I _ _ LoT f6,, 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): m CO. TESTS WERE COMPLETED ON: r ROAD fjT3~I~iION NU7 MBER: PHONE NUMBER (optional): ADDRESS: aU L` Si i `a adr ~ Aj WIS. 54016 CST SIGNATUR r DISTRIBUTION: Original and one copy to Loral Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) --OVER - s t. I.a ~i G F <.to s(I r€ at, p =o t ^l irk. 4. t_ ,.io. Lisa ai t: for L% ( I3"('j €"£F C, 1.i 1C,Cc;I"1%.~ co e., _ ca 1, nr v.1'm v!-! to C !a ihw t F.x f _ ,_a I, i(?s3 en: 1, <t° ~z, C,}~,i°~3s~,t ,?3.€:€ e€~er3 f~?I OFF' .S r,trl~e.;,.k , e i a. E DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.0, BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 OCONVENTIONAL ❑ALTERNATIVE state Planl.O.Number: Ilf a'~igned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRES S.OF PERMIT HOLDER: INSPECTION DATE ~~t :c. • 3 ..•v BENCH MARK IPe manent reference -tI DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. / t .i ! C 'c 41 1 7 1. 'r-= of Plumb : /MPRSW No.: •Count Sanitary Permit Number: I SEPTIC TA /HOLDING TANK: j t l MANUFACTURER: I LIQUID CAPACITY: ATANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER _ PROVIDED: PROVIDED. ~~?.{•>i [DYES ONO [DYES LINO BEDDING: I J VENT DIA.: VENT MATL: HIG AT UMBER OF ROAD: `PROPERTY WELL: BUILDING ENT TFRESH AIR INLET ALARM FEET FROM LINE; IV [DYES V NO NO NEAREST I S' ) DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES LINO [DYES LINO [DYES LINO GALLONS PER CYCLE: PUMPAND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) [DYES LINO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH 101AMI TER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until L FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF DISTR PIPE SPACING COVER- It NSIDE DIA *PI TS LIQUID TRENCHES MATERIAL: DEPTH DIMENSIONS PIT GRAVEL DEPTH FILL DEPTH UISTH PIPE DISTR. PIPE ISTR. PIP MATERIAL . No.. R. NUMBER OF R E TV WELL BUILDING: V NT TO FRESH BELOW PIPES. ABOVE COVER ELEV. INLET E EV. END. PIPES LINE AIR INLET. FEET FROM NEAREST 3 MOUND SYSTEM: Mound site plowed perpendicular to slope Check] the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: rftounO systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- [DYES LI NO 'meets I !the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT M RKERS OBSERVATION WELLS i ❑Y S LINO DYES LINO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES [DYES'' ONO [DYES LINO [DYES NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SP CING JGDEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRE DIMENSIONS NCHES MANIFOLD PUMP MANIFOLD DISTR. P E MANIP OLD MATERIAL NO UISTH JU:ASTHI I DISTHIBUT ION PIPE MATERIAL & MARKING ELEVELEVDIA E LE V. / PIPES D.'. ELEVATION AND DISTRIBUTION INFORMATION 'POLE SIIF HOLE SPACING DHILLELYU HRECILY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS [DYES [_j NO [DYES LINO COMMENTS: PERMANENT MAR KER OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE U YES I NO DYES L] NO _ NEAREST '_7. Lr ~o.?a nXo 1 49 Sketch System on fietain in county file for d t. `l Reverse Side. sl< E n LE DILHR SBD 6710 (R. 01/82) DEPARTMENT OF APPLICATION ~ SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Jyvi(Mailing Address: ~.u saw 134, /9.0,el Property Location: City, Village or Township: County: /VG~J t/a /~✓!cJ'/aS ZD ~T L9 N/ R / E (or) &(>/~S4•t~ Lot Number: Blk No:P : Subdivision Name: Nearest Road, Lake or Lanomark: State Plan I.D. Number: Ilf assigned) TYPE OF BUILDING V /V Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY v~ LIFT PUMP TANK/SIPHON CHAMBER A1,,¢ MANUFACTURER: .;,jTfe;e X EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSE (Square feet): >Q New ❑ Replacement ❑ Experimental .r Seepage Bed ❑ Seepage Pit Alternative (s p C j QZC) /~Xy~ El (p Y) El Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature: o /MPRSW No.: Phone Number: Plumber's Address: Name of Designer: Z Z I"1Q X0 F 524• /t/'O/ ® 1 COUNTY/DEPARTMENT USE ONLY Sign tur of Ruing A nt Sanitary Permit Number: 1 ?_1 Fee ~►-U Date: T_X 1 APPROVED L} Sl DISAPPROVED Reas r Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) REPORT OF INSPECTION INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PFIMARY TREATMENT consists of septic tank. Cesspool. Septic ("ki . Distance from well, feet. Material, Number of comprrtmsnts Total 1buW capacity, (i ( , gallons. Capacity Inlet compartment, - - -V5._ gallons. ~ lr.rlde length. fret. Inside width, foot. Liquid depth, 7 fs set. Cesspool: Distance from well, foot; foutu(atlou. test; nearest lot line at front, ride, rear, feet. Inside diameter. het. Depth, foot. Liquid capacity, gallons. Lining material SECONDARY TREATMENT txsnrirtr of The disposal (told j Seepage pits. Other Tile Disposal lrleldl Distance from well, foot; foundation, foot; nearest lot line at front. ride, ❑ reap (a at. ~ Total length of tile lines:, ;X(_ feat, Number of lines, t ) Distance between lines, (oat, Trench width, inches. Total affective absorption area In bottom of trenches, square fart. inch- Length of each liner fast. Depth, top of Llle to finish grade cal r, TYPO of (liter material: X Gravel. 0 Broken stone. Other Depth of filter material beneath tile, inches. Depth of filter material over tile, inches. Seepage Pits. Number of pits. . Outride diameter, het. Depth, feet. Lining material Distance from well, fear building foundation feet; nearest lot line at [front, side, resr. -fast. Inspection made byl State. County. Local Health Authority, Date of Inspection it a) REPORT OF INSPECTION - INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, feet. Sire of main, inch"- Individual wells 0 err are not customary in neighborhood. G.tva moat recant record of (allure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood ❑ are are not being developed with both Individual water-supply and sawege-dlspoasl systems. Lot rise: ioet wide, too[ deep. Lwellrng set back trom front properly iine, ==t. Individual water supply from, Drilled well. [j Driven well. Dug wall. Bored wall. Distance of well from[ Building foundation, feet; nearest lot line ■t front, side, ❑ rear, (sot' Isetl cast iron sewer, toot; the sewer, feet; septic lank, feat; dispos9l field, feet, seepage pit, feet; cesspool, het; other sources of possible pollution. Wall constructlonl Diameter, Inches. Total depth, feet. Type Of casing, Depth of casing. het, Approximate depth to pumping level of water In wall, feet. Approximate yield, _ gallons per minute. Sealed watertight to depth of foot. Exterior spree around erring sealed with. Q Cement grout. 0 Puddled clay. ❑ Ordinary backfill. Well cover. ❑ Concrete. [j Wood, Metal. Openings in well cover watertight ❑ Yes. No. Pumps lihallow well. Deep well. Length of drop pipe, feet. Pump capacity, gallons per m4tutq. Located In; Basement. L~ Pumproom off basement. Pumphouse above ground, ❑ Pump pit. Pumproom properly drained; Yes. No, Pump mounting watertight: ❑ Yes. 0 No. Type of storage: El Pressure. Gravity. Capacity, -gallons. flaw bacteriological examination of water been made? Yes. No. If answer is "You," give date 19- flow of water [:]is ❑ is not satisfactory for human consumption- Installation does 0 doer not comply with approved exhibits, If any. Inspection made by; State. [ ] County. I.ocal Health Authority. Inspected by b..ta ut iturpection 19 ( Itlr) 'Q' U.S. GOvERNMENT PRINTING OFFICE: 1070-700111/•1