HomeMy WebLinkAbout040-1201-90-000
ocno E m 0 tv r~
o d f c o v1
c 2 9
2 v `D+ 0 fD c
v m x~ ~ n
(1) z o w O O
o v O N O co O A `C
CD 3 m m rn 3
°D ~ rn rn° m Z C) N U w n~
0 0 (o CD
A C a) ° n
N N N W O
CO CO O O O p 7 O O 1-0
O
00 cD O O O N ~l
O) O Q) Q) 3 O
7 N (D O
0 m c
v (_n -G D m P.
v
A m cn N m a
3 0o N
CJ x N:E~ ? 3 CD ET
a c O O
o W QG~ H N 3 \o Q W
CL cSo r ° (D ° (D
c cn r ° cc) C-
0 (D (o (o 0 o r- en
~J (D do H rt Z N W W N cn
N. 0 ~
y H Z 0 0 0 0 ~1
y W W U~ H O = p * * *
c O
r F 00 0 -°o = co i c c ° o
f-- II ,7 N
r v v v C=i o m ~ w9 a
01% N 'o ~
d N O N
I N 0 .d. 7
N m 3 - j N
00 G a a N
Z co Z O
y (D o
0
a
0 o h •
U.) ti
(D v =
c m CD
a
z CD -j cn
O o O A Z
N CzJ f N CL A C 7
c O Z U] ~
H O 1-h I m Z --I rn
d co v m ~
(D (D F-3 a Z
rj T
o E m m m
m ~
n N
rt z
CD
a
a
CL :03 -n
a v
o n
(D
7 N fp`
Ell
CD A
U)
b
n
I ~
I m
O
t
N
N
O
O
A
ti
00 ti
O
CD
Oq V
ti
a
0 a ~ ~
n v, O 9 'D 0
O c d 0 C7 _1
CD w
CD r: ~ ~
-s
m
o
CCDD 3 d m 1 a
00 4~ d. Z _ fA o 0 N
Z) 0
a o
CD M
N N N fl- o 3 N
co CO O O O CD n O O O r"7 ~1
O
0 0 (A (A CD
Q Q 00
CD
I 3 y ~ O O
N c 4o r'7
01 CD
CD Cn CL 3
4~ En
(P N
N E
0 co °W
O
Z8 -0 0 Co CD W
t
W fb CD co W~ N 0 C
O'
0 Q r~ l~l •
Z O O O t~il1
0 0
C) N N y o z
;-Z, p a
v v
o Nv _
L D. CD ~y
(D - CD
N
- d ~
N Cll R • • O N
I ~ a ~ N
a
o Z co Z o
o D a o
tr.
° m CD CD
' CD w N
C(D N
C CD CND
I w ~ (1
Z CD Z (D
n p Z O
v ° C)
0
: Z
v v m
(D M co
CL z
3
00^• U'
9 m
Z
CD
I ~
w
CD n
CL
CD
o
CL
CD w c
z n
o
CD
m
I ~
I s
Co
Cn A
I
A
A
I A
w
N
O
a
A
0 w
CD
CD O
~cn O A
O`{ C b
O CD y
O L ti
r
AS BUILT SANITARY SYSTEM REPORT
e
OWNER TOWNSHIP f~ SEC./, ' N-R ~~jW
T
ADDRESS 90 9 CL~~ ST. CROIX COUNT WISCONSIN.
SUBDIVISION ~e-~Vr L ~U OT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 1163
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
-11 - E?
v
jdiat N r h rr w
BENCHMARK: (Permanent reference Point) Describe: -4p tv
Elevation of vertical reference point: Qrt~~ L- Slope at site:
SEPTIC TANK: Manufacturer:'? e. S Liquid Capacity: Number of rings on cover / Tank manhole cover elevation: H1.
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; Total capacity of 4
distribution lines gallon: size of pump- head;
gallon per minute horsepower ;brand 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; Number of pits feet diameter
feet liquid depth _ seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of li_nes_ 3 width ( length the depth
SEEPAGE TRENCH; width length
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
INSPECTOR--
D A T E D_---- y` P L U M B E R O N J O B---
LICENSE NUMBER
~
f -
r
~ ~ n
v ~ ~
~ r__
' L
~y ~ ~ 'W
°~Y ~ _ how j
1
.:ice"
~ /
w
DEPF,F TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LAB;Ft'& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
-P.O. BOX 7969 BUREAU OF PLUMBING
MADISQN, WI 53707
.
[~dCONVENTIONAL ❑ALTERNATIVE Stfaassigte PlanLD.Number
(lned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Mike Willman 201 WI Ave., Hudson, WI
BENCH MARK (Permanent reference pmt) DESCRIBE IF DIFFERENT FROM PLAN Lot 9, Nordic H e i. g t s i. t i o EF. PT. ELEV.: JCST REF. PT. ELEV..
NE SE, Section 6, T28N-R19W, Town of Troy
Name of Plumber. IMPIMPFISW No.. Coumy. Sanitary Permit Number.
Richard Hopkins 1059 St. Croix 38465
SEPTIC TANK/HOLDING TANK:
MANUFACTURER 1\ LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. -ARN G LABEL LO ING COV
~ PRO DED- PR VIDEO o:
j / ~f
L, G YES ❑ NO A S NO
BEDDING. VENT DIA.: V) TLGH ATER ROADP OPERTV WELL BUI DINGVE TO FRESH
7 AIR IN LET.74 ALAR FEET FROM ❑YES ❑NO NO NEAR ST L7L~
DOSING CHAMBER:
NG
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP ° DEL. PUMP; SIPHON MANUFAC7LIREH. WARNING LAL L COVER
/ PROVIDED. r P tV~11
DED.
❑YES ❑NO ❑YES• bNO YES ❑NO
GALLONS PER CYCLE: PUMP AND CIIN 71ILS oP NANUMBER OF PDPERV EL B LDING vENT To FRESH
(DIFFERENCE BETWEEN FEET FROM NE AIR INLET
PUMP ON AND OFF) Y ` NO NEAREST
j'I NGTH DIAMETER MATE AL NO A RKIN(i
SOIL ABSORPTION SYSTEM. Check the soil moisture at t ede th plowi
or excavation. (If soil can be rolled into a wire, constr lions a cease un 9 FORCE ILI
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGJ NO. OF YDISPIPE F G CO ER BED/TRENCH TREND M Pt1AL PIT DEPTH
DIMENSIONS (I I _5
GRAVEL DEPTH FILL DEPTH 1111TH. PIPE DISTR. PIPE DISTR. PE MATERIAL: O. /ST NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER EL, 1Nf-€T E Ev N(), ~g PIPE I FEET FROM ILIN ' ( A1NL
1iJj '(~/..(~J"'~ L_ NEAREST 7
MO DSYSTEM: r t
76 r- I Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound system to,- ake certain that ON ON REVERSE SIDE. SHOW ELEVA-
meets the crite is for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMA NT MARK RS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH: BED DEPTH OVER TRENCH;' BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑WES ❑ ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO. OF LATERAL SPAC G. GRAVEy DEPTH BELOW PIF FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES /
DIMENSIONS j /
MANIFOLD PUMP MANIFOLD DISTR. PIPE MAN 15 LD MA HIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV.. DIA. ELEV, / PIPES DIA.
ELEVATION AND /
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CONRECTLV COVER MATERIAL
PLANS
❑ .
YES NO ❑YES ❑NO
PERMANENT MARKERS: BSERVATION WELLS: ____jNL1MBER OF PROPERTY WELL: rILDING.
COMMENTS: [FEET FROM LINE
❑ YES El NO ❑ YES ❑ NO {)°S~''. NEAREST
t
Cj . L
Sketch System on Ret n county file for audit.
Reverse Side.
TITLE
DILHR SBD 6710 (R. 01/82)~~
DEPARTMENT OF APPLICATION 3
INDUSTRY, FOR SANITARY SAFETY & B DIVISION
4ABOR 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: Mailing Address:
E- J /
Property ocation: Ci /0"ageownship: County:
2-7% S 6 1 T,, ~ NCR l7 (or) W
of Number: JBSubdivision Name: Nearest Road, Lake ,6r Landmark: State Plan I.D. Number:
(If assigned)
le~
TYPE OF BUILDING y wzwc Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
TSk1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: L S
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ~Vew ❑ Replacement ❑ Experimental 0__m$eepage Bed ❑ Seepage Pit
/ C~ j ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
A Private ❑ Joint ❑ Public is
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Sign" e: #1WMPRSW No.: Phone Number:
, 01/
Plumber's Address: Name o Designer:
iJ
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Agent: Fefe: Date: 1e APPROVED Sanitary rPermit Number:
a (f, (p .ice p ❑ DISAPPROVED 0 V S
Reason for 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)
l~ u r w - 5 7' C 10 0
Owner of Property
)Location of Property / - Section ~ ,'1~ N lt1~_W
Township ,
Mailing Address
Subdivision Name
~T
Lot Number ~j
Previous Owner of Property
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? ' Yes No
Include with this application one of the 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 recorded in the Office of the
County Register of Deeds as Document No. "YS'~/ ' I ~Z ; and that I (we)
presently own the proposed site for the sewage disposal system (or 1 (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 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IND'USTfiY, DIVISION
LA.'AN VD PERCOLATION TESTS (115) MADISOP.O. BOX 76
N W1 53707
HUMAN MI~IAN RELATIONS (H63.090) & Chapter 145.045)
LOCATION SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
/T- N/R r' E (or) W y
COUNTY: OWN-ER'S/BUYERS NAME MAILING ADDRESS:
00
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
(.Residence 1.3 It ,;j.. WNew ❑Replace l ~,f - 1/ r_
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: ri_fl\]-FILL HOLDING TANK: RECOMMENDED SYSTEM.(optional)
$ ❑u 0 $ au 1:1 S ❑u (tom L V7)01 r'?_ (r \ 7-
L~j
&1.5 Sb, j j r -fit, '9'zy ) t3yf_5
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is the
under s.1-163.09(5)(b), indicate: Floodplain, indicate Fioodplain elevation:
~f- PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER- YRtCfiS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH PN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 7 " 13,A), 5l. S L y F. /f! N e, t o
l - s, v
B 5 /3N, sL g3 T{,v, rs w1G,~ , J 7 70 r
t ,L r o ` t eJ. SGT .G~' /3N, G S 43 74
B- 60' Z41V 1/"/ 600psb_ 1:5,
B- C' c' o raAf VL- e 105,
B- Z"Ix3A) Z_~ /.0'r"3N•LI .(n7'ljV,WS"~? $L
4
B-
- PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 1.1 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- Q f,
P- 7 tc~, t t~?k~-glft~i~ ? I 3
P-3 3U ? Lf.~e'
P-
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. 6Q f 7_0 wt Or lit- p z B"1060 VLI' 1
SYSTEM ELEVATION F F f L VA-Fioa OF, Y~ y y
E "a t , i j j I ~ 3
E 1 I I ~ I € j ,
-
)
t }
3
` E
- -
E
,
E
F 1
,
-
f {
3 7 7 3 ~ 1 ~ I
1 3 .
f
1 i
1 ~ j ( t
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 (printl- TESTS WERE COMPLETED ON:
ADDRESS:
CERTIFICATION NUMBER: PHONE NUMBER (optional):
"40 'r
CST SIGNATURE: r}~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Teste,.
DILHR-SBD-6395 (R. 02/82) -OVER
(AwTknw , t' dvanprw;
2, ,.s ..I.. a. is is a , _ a VI: o w ra rc 4 x
1 6 ! ar.
e Conpolp An s ,i .r a iy , a Lyman, A WE WS`_ra f- OR O } E . -S _r , ENa ARE RC,.j : s F F BASED ON VAL . F AV I I O€ S;
consolming theplutplan;
MAKE .A _ . N Dagr a n " t , ,f, Fs k , , . . W ,:«l, 1 1we h " e h A
,nt a", t1o ay'..hoA ai, old w pela1 ,.wilt,
11 aprou'"Yq
r g r , -}tmE_ mF. NQ w chl s rr. a.E ,0Yf -._,~r- h,._ , A. H ,tae}ra3,}}-a'n boX;
Si k.. a-:d . „¢r, your ';?ii'§ a Q,W; ow Vow w N . n a !ntlan:
11 We , fik. coyfl ; ud =rwaburP as i , mcfl AL SOIL , o ,111J1S'T BF 1- H-E D ~ ilH I
=.ai _ IATA _~>=a C..,A'1 >~aIT S RS
Soo .,c'h am! dx €.e Sisk€bais
R i - it d 'swk
11 ;w') u - e oaf ;1 yle
i ' ponor 3" i n£ n'i
Sow F&A,
W
3
~
W,a' r"=; G i-~~r
~ ~ W hi
SWAY < Lxv Win
i't._;, _s:
, r'y
;>,v
c
sm" ISO's 1-6n,
l" t
i now Ank
,°INA 03M
F@La. arsi r. c#1 no My a Srs"1 P_ „3_.n-i J Te rTttwotm ,rr;nayt ques-
!W wi W Am; Or On plivaw,~
a
~IREPORT ON SOIL 13ORiN&S t PERCOLATION TESTS IIS
Poor PLAM PROTEC i r. D.
DA rE - f
HOMESITE TESTING CO.
PT-3, O'NEIL ROAD BOB
"U USO t WIS. 54016 C 5 T SS~ 02 y~Z
i
PROPOSED MoVSE MUST LIE Z~ Fr• pe MORE FiPOM AL[ TEST f;~PEAS,
PRo POSED WEa M v5r we 5SO Fr a,Q MORE F~Po.►~
,9cc T£sT ~,PE~s,
• = l3At,~fj/oE ~°%TS Q = EJp'iST~NG- ~cIELL
1( ~E~G ~OCgr/D~Uf = yA,VD f}v9E~PE0 o,Q 57,4011EL Bowr5
• ° f/o,~iz . BM ~£,~Tic~+~ ,PEfERtwcE Po:0T
LE GE N D/EV~row oA gar. ,PEA Pr
rV v) L (77- //,,,A,
f
G~ i yfOf,1
?2
Go ~
C
Ax
P1
z
z5
ejQ.i .SO ~ 34~
x
/OJr ~ d
t t
f
J, ell K~ N° ~ ~ G , TO ~ e f /1 c~C Gv o t
ell* ` j me, n 3
ST. CROIX COUNTY
WISCONSIN
r 4. t`F S ,~~r
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
TTT
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
EXISTING SEPTIC SYSTEM AFFIDAVIT
The existing septic system which serves the dwelling being added on
to must be inspected by a licensed soil tester for compliance with
high ground water and/or bedrock seperation requirements as set
forth in s. ILHR Chapter 83.10(2) WI. ADM. CODE. The results of
that inspection must be made available to this office. If the
existing septic system meets these minimum requirements, and is
properly functioning, an addition may be added to the dwelling
without updating that system. This addition must not, however,
encroach upon the required septic system setbacks as setforth in s.
ILHR Chapter 83.10(1).
Property Owner (s)
Property Mailing Address:-
lfccdrSoh , ~r ~`~o/G
Property Legal
n/Description: Lot --2_CSM/Subdivision ~ori~'~ e1y~~S
1/4 Y-'-1/4. Sec. T• f X N. , R.Y-Lw., Tn. of
I, as the owner of the above described property, hereby affirm that
the septic system serving this dwelling meets the above referenced
state private sewage system codes. I realize that this addition
may cause the existing septic system to become undersized for a
dwelling of the resulting size, and I will make this information
available to any future parties interested in purchasing this
property.
Notary Public
Subscribed and sworn to
be re me on this date :
Signed:
Date: / Z
My commission expires:
95-