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T,?~N-R_2'~_W ADDRESS'rST. CRUIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 ®SHOW ERYl'HING WITHIN 100 FEET OF SYSTEM -7 J- I 1 - I dilate N r h rr w ~re; al" BENCHMARK: (Permanent reference Point) Describe: Lr'c CP~O~ Elevation of vertical reference point G'"c~L~ Slope at site: 3 SEPTIC TANK: Manufacturer: ) ~,p. Liquid Capacity:_~p . Number of rings on cover _ y r Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump et or a c c e_~ gallons; Total capacity of distribution lines ga size of pump_ _ head; gallon per minuteho sepower___ ;brand name of pump and model number Type of warning devi HOLDING TANK: Manufact rer Number of gallons Elevation of man '01 couer Type of warning dev' e SEEPAGE PIT SIZE; umber of pits feet diameter feet liquid depth s epage pit inlet pipe-elevation bottom of seepage pit eleation feet. ~~J+y SEEPAGE BED SIZE: number of lines _3 width_ /A length" tile depth SEEPAGE TRENCH: width__ _ length PERCOLA'T ION RATE AREA REQUIRED AREA AS BUILT 2,::2S INSPECTOR DATED PLUMBER ON LICENSE NUMBER <; UEPARTWENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 RXICONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: l El Holding Tank ❑ In-Ground Pressure El Mound Ilr ass~9n ed NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER'. INSPECTION ATE. Jerome Delwiche 115 S. Falls, River Falls, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PIT ELEV.. SW SW, Section 16, T28N-R19W, Town of Troy Name of Plumber. IMP/MP.SW No.. County Sanitary Permit Number. Walter Nechville 003253 St. Croix 38461 SEPTIC TANK/HOLDING TANK: MANUFACTURER. TANK INLET ELEV.. JTANK OUTLET ELEV.. WARNING LABEL LOCKI G V LIQUID CAPACITY pR VIDED: PROV E q YES ENO Es ❑No BEDDING. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY' WELL. BUILDING VENT TO FRESH ALARM. FEET FROM LINE. O ' AIR/ IN DYES ENO EYES ❑ O NEAREST DOSING CHAMBER: NG COVER MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER IWARNING LABEL T PROVIDED. DED-. DYES ENO f~ DYES EES ENO GALLONS PER CYCLE: PUMP DCO ROLS OPERATIONAL NUMBER OF PROPERTY [11 LL (VENT TO FRESH IFFERENCE BETWEEN FEET FROM LINE AIR INLET (D PUMP ON AND OFF) DYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ]TFN(TH JDIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LENGTH NO. OF IDIST11. PIPE SPACING COVER INSI DE DIA. UPITS LIQUID BED/TRENCH ,-T TRENCHES. MAT~F L: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH JDISTR. PE DST PE D STRNUMBER OF WBELOW PIPts ABOVE COVERELLEVI ILET ELEVR EPNDJ ye PIPES FEET FROM !PROPERTY, LINE-j R LET. J T). E 2"21l 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: moumd'systems to ake certain that it ON REVERSE SIDE. SHOW ELEVA- mee#s 1~ e criteria for edium sand. TIONS MEASURED. EYES ENO SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS DYES ENO DYES ENO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED JDEBT OF 070, L. SODDED SEEDED MULCHED CENTER EDGES. EYES ENO DYES ENO DYES NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING] GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES I DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL.' NO. DISTR JD PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVELEVDIAELEV/ PIPESDA. ELEVATION AND S DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PVERT LAN ICAL LIFT CORRESPONDS TO APPROVED DYES ENO DYES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELL NUMBER OF PROPERTY WELL: BUILDING. i FEET FROM LINE j nl DYES ENO EYES ENO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) DEPARTMENT OF APPLICATION 3 SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LA43OR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,'WI 53707 i 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. Pr ert o e~ , Mailing Address: ~c.~J1.5- Property ~k~ L~ y~'~Ya Location: City, Village o ownshi County: G~ '/4 '/4S j(o IT ~2 Ni R J 9 E (or (k rn, 5 f, Lot Number: Blk No : Subdivisio Name: Nearest Road, Lake or Landmark: State Plan I. D. Number: v (If assigned) /V,9 TYPE OF BUILDING ❑ Public* ❑ Variance* ❑ Other (specify) Number of Bedrooms: 2~- 1 or 2 Family *State Approval Required. 41- 1 TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY / X O O N a lv q A N HOLDING TANK CAPACITY Ai 14 LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: LJ C.orc~x~R EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 9 "Seepage Bed ❑ Seepage Pit (o S~~ 8 /29X '4 (Q ❑ 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. Na me of Plumber: Signature: M PRSW N Phone Number: y tlo Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signat re of Issuing Age t: Fee;:/~ ~ Date: I~ APPROVED Sanitary Permit Number: lq- J fTG/ we 9-(~- ❑ DISAPPROVED 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) j No, r km T ~ R 41 i 0_ x I _ ~1 S a ~ n do ` i Icy #Vb Gc 7 `i DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & IiU1L N INDUS°i`f~Y, DIVISION P.O. BOX 796 LAi3OR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: ELK. NO.: SUBDIVISION NAME: sty '/a 1/4 /6 /T9N/Rt E (or 7/eOl COUNTY: OWNER'S/BUYER'S N~IE: MAILING ADDRESS: 57`• CAI)( TCRD M E U~'GI.U%Ght= //5 Sov~, '05w1 S /o IV" le)1S S~o-ZL USE DATES OBSERVATIONS MADE e O ATI~O/N TESTS: NO.BEDRMS.: COMMERCIAL DESCRIPTION: ~j PROFILE DESCRIII/PTIONS: PER -T_-- x New Replace F3 2- sidenc N+- 0,4 j RATING: S= Site suitable for system U= Site unsuitable for system - ~ 515,~Z-7F2- CONVENTIONAL: MOUND: lN-GROUNDPRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMNIFNDED SYSTEM: (optional) 61 sue, Fl' S ou ©S ❑u I NS au o s ©uS__au 7bvoz".yii ml ~3E1~ /~'J If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: yr PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-TRTCtFEE CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH M. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 1.3 ' -6y. /.p' F3 ' Ove- 4vh' e s'L, /.403 ' B- 1 (I.0 /o/. If ~ y 4 • a Aix. if fAAJ' S - L5 ha• of 7A U L'S ? T4Aj GAS . J / 41AZ5z; (2,z. ~j ' I )f `D,l' Av. L) . 7Jf ',QU. 17 ` Y• aF O,A-/,3,U. L S B- 3 j ' •lci7 `DE A), L -7S, B- y '~•d 0/ (a7 Av- } Q 5 3 ' hi,~. o .V L` .~4a /,o ' /~N• SGT 0.3 3 Af/Y- of 74A' B. 0 0.13 yle' B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TE5TTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD t ERIOD 2 PERIO 3 PER INCH P- P- r P P- / s ` co 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 e_~levattion at all borings and the direction and percent of land slope. / oT ~^QM 6G G xe,4UW-1e-V "L CTz 3. os / SYSTEM ELE"TIDN /3E-~ow UE•~i ~t~ !~T fT 7-1T 9~c1 of 9~ 9~' i { Se -IS W I , I I i 1 ~ ( ? 11 i fi c N , w s ,g T'iew 'A/ o T r' % sine & TToM__._ Tio/v 41r, & e Sw-~ J _ 1535Y T 101-/?!.l~ ,7"O u. E FT . _ _ D cK-P U -716 5T 14 -:-h-/30 U'F` : i~c 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. i NAME (print): TESTS WERE COMPLETED ON: Igo d"7- 7- *41 CERTIFICATION NUMBER: PHONE NUMBER (optional): ADD e,T 3 AV h~oDSo,cJ ' SIGNATURE / DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soi! Tester. DILHR-SBD-6 95 i,R. ^2/62) - OVER - L ' REPORT ON SOIL 60RNGS PERCOLATIoN TESTS l is- J ,DAY Z~CGw%aE- 7-21WNs r lley PLOT- PLAN PROTECT r. D- o y 7okS/Ip. ' '5Y- oo// ee--. DArE Zy-03 HOMESITE TESTING CO, R-1-3, VNEIL fdtDAD BOB U1,1;R C, A A:,'ivSON, WIS. 54016 CyT -S- GL yfZ PROPOSED HoosE MUST LAr z_;, Fr oR 1orr reaxr ,gEc T~sT /3,PE~35, PRo POSE O W L LL M V5T we 50F- T o.p iyp,QF F~POrr Ate TEST ^0445. ~E,PG /oegrsow~ = ffANP ROv C PED o,Q 5,40atL 134eE5 Peo Oo7-oN ~'E.HE.l1T r = e; 7- - BM "Sam VtPri AL ,PEAiRh-A)C - P61~O T PeA~ sr-4L u, 5 11V i pc f i - Pot-i,4 ~-F poWe e Ao X . LEGEND 641VArdAl of IJlMr. ~P~f. PT /o D • D F7-- P '4 vE Z- r _ ~ I ! 7 A r fox is a potot)e f{o~'2, /-~l`'1 • Zy y'S ~ ~ i NOME k zs s lrE i 1Q~'~ / , j SYSTEM ~ qo" 03 1~0 Ik i f / ~}fTERNATE ! 1 qPL Ar . v y V soup, Hof;,~E - - - ►5 Form - S T C 100 Owner of Property j'FSS/~/,~ tJ (~L (~v" /Cjf= "Location of Property S 6x) 14 4, Section T N R_W Township Mailing Address Subdivision Name Lot Number Previous Owner of Property )-1-7; 'yC J Total Size of Parcel 7>, `j A Cd~= S Date Parcel Was Created 1 rc~~ -f^ 6'E C' 3 53k a Are all corners identifiable? Yes No Include with this application one of the following: Certified Survey Map Deed .Land Contract, or .Other I:;egal 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. --:L/ 3 i CE ; 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. SIGNATURE OF OWNER SIG/fAATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED/