HomeMy WebLinkAbout161-1095-20-000
n cn O 3 v n d
o c m o
CD 3 n 3
0 (D
CD A)
(D
` 1
3 F 5
o w "s
03i O m O A N < W m •
3 v N
(D M N N O O
co Q W z C7 y O O O
W O 3 U O ? O O O O
(D UT N a O r v
_ r ry
C) CD 0 Ul
C @
7 O
3 y a _ O C
O (D N O_
Co cn < D a m o
CD m m a Cl) 'Z)
w
W I~
3 0 ~ ~ °
r
C7 V
i woo ° ~ "%IVA
(D
N o0 o co O ~ O c
w w s m Z
=
o o o a !r•
z O O O
C-n x.
C)
Cl)
8
m
N O.
3 I'' 11 v
CL =3
z
N
zco z o
CD 0
m D
O Z
o' c h
D (n
(D co q
(O N
C (D (D
Cl) (D a
z CD I(6 1 ,
Z (ND
a a z
O
0
W (D m
CL 3 z
0 :r U O
w z
(D A
W
C1
(D O d
C 7 Q
CD N
DDa m c
(n m z
cn O o d
~cD 3 N m
N
O N~ v
d o-
0 0 3 0 7 A
n -
(D (11 l< y
3 5":- A
j = O dc
-a (D CD A
ti
N 0 0 7 O
7 "O p O VC+a
2 7
O O 7 j N
X
CD qz~
0 O
(D a
O CL A
0 b
O
Oq
O
O
O 0 ~ O
ays
O L ti 'y
DEPARTMENT OF APPLICATION
NDUSTR'f
INDUSTRY,
LABOR US AND FOR SANITARY SAFETY & BUILDIN DIVISl
HUMAN RELATIONS (PL13 PERMIT P.O. 7 i
67) 6 . BOX 7S
MADISON, WI 5376
Attach plans for the system on paper not less than 8'/Z x 11 inches in size. Include a plot plan that is dimensioned or drawn to
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics asspecified
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If scale.
designed e. by Horizontal
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner' in chapter
included.
a Master
s copy must be
Mr/5EA l Mailing Address: _ Ssd7s_'
Prop erty.Owner:
CZ/V S.
Property LocatioGn: /V Z j s
5W %5'Z0 40 %aS /2- ~T 2 9NiR ZO E (or W ~ age Count y/P6!✓6'/TE7`
Lot Number: Blk No
3 Subdivisio n Name:
c Lt T Nearest Road, Lake or Landmark:
State Plan I.D. Number:
TYPE OF BUILDING N BEST (lf assigned)
❑ Public* * I
❑ Variance ❑ Other (specify)*
or 2 Family *State Approval Number of
d 1 Required. Bedrooms:
TOTAL NUMB GALLONS O TANKS PREFAB POURED-IN
SEPTIC TANK CAPACITY CONCRETE PLACE STEEL FIBERGLASS NEW REPLACE- OTHER
~o INSTALLATION MENT (Specify)
HOLDING TANK CAPACITY ti
LIFT PUMP TANK/SIPHON CHAMBER X
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM /~'1/¢ E lC
0011,
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ,
4,
2 ❑ Replacement
❑ Experimental jky Seepage Bed ❑ Seepage Pit
❑ Alternative (specify)
/ ❑ Seepage Trench
Water Supply:
Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber.
of Si ture:
~ MP/MPRSW No.: Phone Number:
Plumber's Address: /
«
Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing A nt:
Fee: 0 Date:
APPROVED Sanitary Permit Number:
Reason for Disapproval: t7 DISAPPROVED 39 -7
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 coun
stallation. Failure to comply will void the sanitary permit.
ty prior to in-
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
PE RTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
40R'& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
.0. BOX 796*1 BUREAU OF PLUMBING
MAG•iSON, WI 53707
rted umber.
liCONVENTIONAL ❑ALTERNATIVE (SlftatasesPll9ned)
❑ Holding Tank El In-Ground Pressure El Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Len Meissen 1922 55th St. Ct. ,InverT~Gr. HtS.MN :y-=3 1~-
BENCH MARK (Permanent reference pmm) DESCRIBE IF DIFFERENT FROM PLAN Vill. Q N o r t Hu son REF. PT. ELEV.: CST REF. PT. ELEV..
SW SW, Section 12, Lot 31,St. Croix Station T29N-R20W
Name of Plumber. MP/MPRSW No County. Sanitary Permit Number:
Anthony Zappa 1614 St. Croix 38474
SEPTIC TANK/HOLDING TANK: •'j G
MANUFACTURER: • LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOC G C ER
ROV ED. PR
YES ❑N0 ❑NO
BEDDING VENTDI ENT MATIL HIGH WATER NUMBER OF ROAD PROPERTY WELL BUILDING. 1VENT TO FRESH
ALARM LINE _ IAIR INLET.
I F C )I, I i( ❑YES FIND NEAREST
❑YES NO
IFE iiA
DOSING CAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY P MODEL. PU IPHON MANUFACTURER WARN ABEL OCKING COVER
PRO E PROVIDED:
❑YES ❑NO Y S FIN YES ❑NO
GALLONS PER CYCLE: PUMP D oNTRO s RAT oNAL NUMBER OF RNE ERr WELL uiLDt G I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM AIR INLET
PUMP ON AND OFF) YE NO NEAREST ;
SOIL ABSORPTION SYSTEM. Check the soil moiSt6 at th de h of plow ng LFNC,TH IDIAM I Ey H ATERIA AND MARKIN
or excavation. (If soil can be rolled into a wire, ct~ structio shall cease until FORCE
MAIN If
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING. COVER ITS LIQUID
BED/TRENCH TREN.%. ro H PDEPTH.
DIMENSIONS Le r
GHAVF DEPTH FILL DEPTH UIS TH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: O R. NUMBER OF ELLBUILDINGVENT TO FRESH
BE LOW IPFS
V+~COVER ELEVNLET ELEV. END AIR INLETI7 FEET FROM MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of th material for PROVI A IIIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to e I tain that it ON VERS SIDE. SHOW ELEVA-
meets the criteria f rfinedium and. TI S MEArSURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKER S BSERVATION WELLS
❑
❑YES ❑NO ❑YES NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH,'BED DEPTH OF TOPSOIL. SODDED EEDED / MULCHED
CENTER EDGES.
YES FIND:'{ ❑YE,..FIND ❑YES FIND
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO. OF L SPACING. GRAVEL EPTH BELOW PIPE. / FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS ATE Fyt I'll
MANIFOLD PUMP MANIFOLD I$rTR. PIPE JMODISTRDISTRPIPE DISTRIBUTION PIPE MATERIAL MARKING
I'd
ELEVELEVCIAEYE V.PIPES. DIA.
ELEVATION AND /
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CT'E CTLV COVER MATERIAL
PLANS
FIND ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OELLS: NUM 3 ER OF PROPERTY WELL: BUILDING. FEE FROM LINE
❑YES ❑NO ❑YES ❑NO INEA ST
>
C1 `1~ `f
F~. It lSv -Tor
Sketch System on l in county file for auP
Reverse Side.
SIGN RE TITLE.
DILHR SBD 6710 (R. 01/82)
Fu rul - S T C 100
Owner of Property le
Location of Property Section /_Z_,T N R2_W
`township _ )/'e_:'C- q--f
Mailing Address_,'/e('1r
OK/
Subdivision Name r'
Lot Number
Previous Owner of Property--
Total Size of Parcel I, ,~Ll ~E!
Date Parcel Was Created
Are all corners identifiable? _ Yes _No
_ II
Include with this LU)_pIi.c Ition one of tlir following
.Certified Survey Map
.Deed
.Land Contract, or
.Other Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed rVcpr d i the Office of the
County Register of Deeds as Document No. and that I (we)
presently own the proposed 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.
SIGNATU~RyE,OF OWNER 5 NATURE OF CO-OWNER (IF PPLICABLE)
DATE SIGNED DA, SIGNED
AS BUILT SANITARY SYSTEM REPORT
0WNEItf W at N0a SEC. -R61 Ow
/YU J o N
ADDRESS S,r CROIX COUNTY, WISCONSIN.
SUBDIVISION tTj'LOI--_ LO':I SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 1163
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
fl=
i
w
W
-41 IA-L S12
7
- To Xr,
610f ZL
r z;,4
L
c4f
p . rw y C
Ii di t N r h rr w
Fa- 77-
BENCHMARK: (Permanent reference Point) Describe:
t:
Elevation of vertical reference point: Z(2(],C>0 Slope at site: jJ
SEPTIC TANK: Manufacturer: - Liquid Capacity:_U
Number of rings on cover _ _Tank manhole cover elevatio
_ Tank Inlet Elevation: 'T'ank Outlet Elevation: .
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle- -gallons; Total capacity of
distribution lines _ gallon - size of pump head;
gallon per minute horsepower ;brand name of pump
and model number
'T'ype of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover- ;
Type of warning device _
SEEPAGE PIT SIZE; Number of pits- _ feet diameter
feet liquid depth-- seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines 1 7 width CtO length ~ the depth
SEEPAGE TRENCH: width _ length_
PERCOLATION RATE AREA REQUIRED O a() AREA AS BUILT 61 )
INSPECTOR
DATED PLUMBER ON JOB G,90,cy Z9AAA
LICENSE NUMBER C-e-1 j-~e
'PARTMEVTOF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
)USTRY; DIVISION
,BOR AN,D PERCOLATION TESTS (115) MADISON BO 53707
j,MAlN. RELAI IONS
(1-163.090) & Chapter 145.045) LOC
A TI '/4 S 7ION; `~E (o~ TUIVORY- NICIPALITY: L J `U.: BLK. NO.: FU~E vl~~Xu5r472GA"
COUNTY: ! OWNER'/S//BUYER'S1 I VRNAME:, MAILING ADDRESS: 5f
C~0/ ~~Jv ~SS~ni l9zz ff Sf ef'. i-t/~E,~ C~dc' ~{c fS ~(~v.
USE DATES OBSERVATIONS MADE S
! NO. "BE~~DRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLA ION TESTS:
f ZResidence /V New ❑Replace '/y'P3 /~•~exL 3 yap
'
RATING: S= Site suitable for system U= Site unsuitable for system
'CONVENTIONAL: MOUND: GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM! (optionailreVjVEA%l1eA) 9L
LYs ❑ [IS a INOj u~asU ~s DU ~ z.F, u X.j
If Percolation Tests are NOT reffl! GN RATE : If any portion of the tested area is in the ~r
under s.H63.09(5)(b), indicate: vim- I Floodplain, indicate Floodplain elevation:
Fr PROF~E DESCRIPTIONS
80RINGII TOTAL DEPTH TO GROUNDWATER-I S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
3UMBEROEPTHIN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B_ 0 08 o J03 ' aAJ,1-S, 5; 66 ' L/. 60.
> • 33 `1~E /3r1.LS j 6`7' X~`• LS} (S.6 6,v.
y9 0Gn ~A ) Ieey-
- y/ /,J. LSD I. ' /:'.v -6x LSD / 7 " AAj' LS
IB_3 / ~Q ~~Q ]'hi'Y. Occtef5 01"J C5
p~c~~TS ~ L~•G'~l.L.S .
B- ~,1~ Viz'- > o /f'Gi~ U'
/ /,'Yj' A Aw,1_5 j , yT ' L-5, 45,
'
77
LO" 04
FT PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NIJP'BER ES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- l1% c/ 2
_7z
P-Lill
P- 0
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. 13oT/rem o,--- /QED EXC/~11gT/GIN .S/i Al / FT. 13" fe'ncr_
SYSTEM. ELEVATION ~/ERrCA c ,F'EF Pi . d>9r/eA.., aF ~J , aCv ~T
Fit
T
• _
1
t ,
,
I I I d ~ i i
t
L
! . t
5j
_
J t f - I i
I i _ i t I I ' i I
i
i
. t t
1, 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.
TESTS COMPLETED N
/T 0,66- _r7 / 9O 3
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
O~L
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
-
DILHR.SBD-6395 (R. 02/82) OVER
916PORT ON Soil 130RiNGS PERCOLATION TESTS 11S
t, f r ;'Ici r 'o -
P O T PLAM PRoTEC I r• D. r=!'x
DATE 4/1/',,~ /
HOMESITE TESTING CO.
n"r,3, O'NEIL ROAD BOB I u;jac
allDSONt WIS..- 54016 C57- S-
02 31,f 2-
PROPOSED HovsE Mosr 6e Z,,~ Fr o,~ Mote F~PoM A~~ TEST ,,ve.45.
PRo POSE D we u M vsr we So FT o,e Aoer Fxo ti A1
TEST
• = 9AU*,oX- PIi 73 0 = EXiSrl V 6- !.(SELL
X = ~E~QG /OCgT~ONf = f~A,1J~ f}tl EKED o,Q 57,4011EL 134er5
• = f/o,~iz . B M ~£~1ric~a~ ,P~~ERt:vcE- Poi~T~
LEGEN D 454 V,4riov OA var.
,k;P, 7 7z y ~-/v,
L o -r 31
3 r:sf~ '
N SEi (3ot-
yG " S O ~ t TES i ER
< ~~h
VEI~r/CAL ~~-GER M«" " ! °N X457-101'
Pt 11,4 / io/v = i o 0. 6
a
w v
,c -
v'
~ i
~ j
- s i
S ';w
Go7!_flf..:C~!2L' `i O_ 3 to
-o
-o -
N N
v±
~O
~o Z
aIV
s ~f P
I' Ha ~'Q =
3
q PLE3 ~7
i
°P PLOT and CRO55
Ali :off ~ ~rl f o~ E C-cTI O N PANS
131) 'eE Z. I s ~l ; 4'
L -
c. s~
17 ob
E
I I
LIN M,1111f v 11kc, M I SS~~ S
Z> dad GC)l S 1-~•~ ko
A.)
S I 'GNFD
Fresh Air Inlets And Observation Pipe
Sots TESTINy By
HOMESITE TEST.'NG Approved Vent Cap
RT.-3, t%°NEIL RC),,,,)
HUDSON, WIS. ".04om Minimum 12" Above
Final Grade
4" Cast Iron
Above Pipe -
i o Final Grade Vent Pipe
Marsh Hay Or Synthetic Covering
min. 2" Aggregate
Over Pipe
~y Distribution Tee
Pipe 0 0 0 0 0
Aggregate 0 Perforated Pipe Below
' Beneath Pipe 0 Coupling Terminating At
Bottom Of System