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HomeMy WebLinkAbout040-1160-30-000 1 n N O 'o n C y F 7' C CD _1 7 Q m M 14. O C ~ ~ 41 # f0 A O U v m o ° w o cNn ° °C • CJ7 S IV O I~1 r~ (.J (D 7 lD 0 O (D CO C' fp Z n N --I C\ ` O m [ 1 N Q o rn° 1 O -0 h 7 > O cNn O , twOr 3 ' W ea o O N N co m U) D a N v a v = W C: C. 0 C. CD Fw~ O w l~ fn C (n Z CD CD o r- cn o R o Z co w c N rn ov oN c'i• ~ ~ ° I o o ~t ti °o ai can can D it C °°0'Ic ~o •4> Z `S 7 N d• N (D (D CD W `Z ill N 6f N '--1 Z CJt lJ`I _ m CD 00 u7 z Z Z W O Z O r- v v ~ D a -~D c~° rn o cn N+r . CD N oo ~ v 1 W O O N d -'cam W ~ ~J oo pn OZ = ca A Z M y> W t- Z N K oa rn N CL A 7 Cis ~ Z Z I p r A V 1 v \1 Z --I N A W q m Z LTI o Cn a 3 \ N y m O-~ Z ~ A (D A f v C N ` Cl) :E Gi " { CI'1 vv l` ? d C n a G N T n C z a o CD CD o a O A d ~ N n C S t0 CD O+ O 1 •O O O V 3 ti p M p H CD A O CD 0 p Opp fA 0 ti O C a C:) CL A AS BUILT SANITARY SYSTEM REPORT SEC x-,S T"?N - R 2 C W OWNER TOWNSHIP _ ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 Inl_ LVLRYTHING WITHIN 100 Fl'1:T OF SYSTLPI - - - i s t _ -rT 4) l 96 7/ I di ate or, th~ A roe 4 SCAL 1 . - BENCHMARK: (Permanent reference Point) Describe: -9 A.'` Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: /e- ~ ( fAL Number of rings on cover Tank 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 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 o pits feet diameter feet liquid depth seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines t width le-agth_,~t, tile depth.-'r SEEPAGE TRENCH: width length PERCOLATION RATE <,3 AREA REQUIRED AREA AS BUNT - [ rp y INSPECTOR- DATED PLUMBER ON JOB T- LICENSE NUMBER DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 , BUREAU OF PLUMBING MADISON, WI 53707 C CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number Ilf assigned) ❑ Holding Tank El In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPEC ION DATE. John J. Sehet6 00 F. 4th, St. Pau. MN 55101 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PL ELEV.. NE% NWz14, Sec. 25, T28N-R20W, Lot 1, Town o6 TItoy Name of Plumber. IMP/MPRSW No.. C . Sanitary Permit Number: Anthony Zappa 1614 St. Croix 43651 SEPTIC TANK/HOLDING TANK: MANUFACTURER. ' LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL ILICKING COVER Jl ! PROVIDED PROVIDED 1✓~ ~t;~ i t r ` ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA ra VENT MATLY, HIGH WATER NUMBER OF + ROAD PROPERTY WELL: B UILDINGVENTO FRESH J J I ALARM . FEET FROM LINE r , AIR ITN L E'eT,.: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST { DOSING CHAMBER: MANUFACTURER BEDDING'. ILIOUID CAPACITY JPUMP MODEL PUMP/SIPHON MAN OF ACTIIR ER W I G LABEL LOCKING COVER E P.AOVI ED:~---II,.. OVIDED'. ❑YES ❑NO ❑ ESl LINO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER F PROP TV ELL BUILDING I (DIFFERENCE BETWEEN FEET F LIN AIR INLET. PUMP ON AND OFF) ❑YES ❑NO NEARE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH D ETEH ATERIAL AND MARKING or excavation. (If 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 J INSIDE DIA. 4PITS. LIQUID BED/TRENCH TRENCHES: MATERIAL PIT _ DEPTH'. DIMENSIONS GRAVEL. DEPTH FILLD PT DI PI DISTR PIPE DISTR. PIPE MATERIAL. NO:DISY NUMBER OF PRDPERTY WELL. BUILDING VENT TO FRESH . BELOW PIPE S ABOVE COVER . ELE V.INLET ELEV END. PIPES . FEET FROM L16N" /7^ ` AIR INLET 3 w{ 41 8~ ~~i 7 NEAREST----P- /~vlJ 7 ✓ MOUND TEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE jP111MAN T MARKER OBSERVATION WELLS 4YES _ ❑NO ❑YES ❑NO DEPTH OVER TRENCH: BED DEPTH OVER TR ENCHBED DEPTH OF TOPSOIL i SODDED SEEDED MULCHED CENTER I EDGES ❑ ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL PTH BELOW PIPE FILL DEPTH ABOVE COVEN. BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOL MATERIAL. NO. DIST DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV.. DIA.. ELE V.: PIPES'. DIA.: ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIA PLANS. ❑Y❑NO' ❑YES ❑NO COMMENTS: PERMANENT MARKERS- OBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑ YES jND ❑ YES El NO NEAREST • ry 1 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) f APPLICATION FOR SANITARY PERMIT' t - w_ L -COUNTY i ~ UNIFORM SANITARY PERMIT innus-~ eior,~ Duman ae~c>Ti°ns ' f. ~ f -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 PROPERTY OWNER MAILING ADDRESS TO ///V -T" Ifs/` C~ t) = jJ PROPERTY LOCATION CITY- - /(r~~ ""'1 11.1 l AGE: ~~~V "7 V 1/4 Al /_4, S ZS , T fN, R E (or?e (1! TOWN OF:~ LOTjNUMBER BLOCK NUMBER SUBDIVISION NAME j NEAREST ROAD, LAKE OR LANDMARK STATE PLAN LD tv !MEEK TYPE OF BUILDING OR USE SERVED L 1 or 2 Family Number of Bedro)rns: L] Public (Specify): THIS PERMIT IS FOR A: Ki 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. '-S~,Seepaye Bed ❑ 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 A44- :1anufacturer: / y LrcJ/ f C.l~ t j fr Q C© t) e tP OY-)""e / 3 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 Capacity Lift Pump/Siphon Chamber V,anufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSE (Square Feet): 61 630 ~'f ~ j 3 Private El Joint 11 Public i, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: mm MP MPRSW No.: Phone Number Plumber' Address: Name of Designer: ~ 71Z ~'16~~OE~ sT /y4~ 11tlOf04_) COUNTY/DEPARTMENT USE ONLY 4 Signature of Issuing Agent: Fee: Date: ❑ Disapproved _ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR SBO-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber t~urm - S '1' C 100 Owner of Property Location of Property 4 N 4i Section Z`r Z5N R 'f7,0 W 0WnshiP 1 ~.0 Mailing Address Vit-ic, Subdivision Name GSM ✓_~7~ l/o1 yis /Lye Lot Number Nprl~ Previous Owner of Property,-- Total Size of Parcel S Date Parcel Was Created- Are all corners identifiable? Yes No Include with this application one of the followi v: .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION (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.~1.S7~1 ; 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 dul recorded in the Office of the County Regis er of Deeds, as Document No. (GNAT RE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED (o7 PLOT and IR055 jn~ SECTIO14 PIANS `P i61P cR PP QV O 7 0 jot/ lip 7 ~ e I ~ Stiff ~ E G ~a NED L ~CE~tIS~ TAT I Fresh Air Inlets And Observation Pipe Sa[~ TEST?►J~ By HOMESITE TES -NG t:o. Cam- Approved Vent Cap 127..E C'ii'~E I Cn ' , HUDSON, WIS. '-4016 Minimum 12° Above Final Grade M kY j 1-r UNI o ` J~-" Above Pipe 4" Cast Iron To Final Grade Vent Pipe JO H A) SC Marsh Hay Or Synthetic Covering O ~CT~ Min. 2" Aggregate Over Pipe / NtJ c a 4~ D Distribution Tee l~ N, W20 w pipe o 0 0 0 o i,Qb y ::Tr11~- -v n1/ ;3 Aggregate LL- f ertoratad ipe Below Beneath Pipe Coupling Terminating At 5 Bottom Of System i v y~~R • ~ #.4) IN DUSI MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS USTf3Y, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) Alh) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO :BLK. NO.: SUBDIVISION NAME: #,i5' 1/ '/a /T,2.9 N/R 20 E f or W i,~e;✓ CS" - I L COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 5 , C ?G~ .ti S cf0 5~~ k'T USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATIO TESTS: ~T .idence A / New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system s S /3,)A Ai t" '/(u) /,r 5-Z- CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ES ❑u KS ❑❑ul ~ S ❑u ❑ s au ❑ S DU If Percolation Tests are NOT required DESIGN RATE: r 5 I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: /LIA, 7~0J0 PROFILE DESCRIPTIONS le 1_0 BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) IW 1// ,S r G , q 3 X.~ d.f' Iha~Q. 5 B- 1-1.0 76. 173.(p B- 0 ot. 27 P.S OA 54 TA A; C'S - z. • - 13 A) C e , !3N Si , /.y ' L7/. av. L / 9~ ° hiX• B- 714A,) c5 t!. ,J ~z. 9'7 zCv fir- sc a0. , S, ~ r,4W Cw - ~ko B- 12.0 ~ 100, 3 74u- 7 Id 0' 75- L; ~ '~,r Q,, . ~s-° J'/. ,3.J. sue, P J C rv 0 r K f° a S .06 > Y3 B- OR s• ~ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN f•-✓° AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH P- t1. P-2i - P- P- 7 61 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 yo percent of land slope. 13-01-7-0m Or-- 'Jep % ~y / o SYSTEM ELEVATION /3P 1o-o V64F&A~- Ccle-tl•TTacc,) QF - -y - i t e 3 4 3 ^40L, L I j t : 1 4 t I ? I k ~r a - - 3 _i E t € ( ~ I j 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 thye~locatiyo~nyof the tests are correct to the best of my knowledge and belief. BOB NAME (print): TESTS WERE COMPLETED ON: HOMESITE TESTING CO. / 7 - 93 ADDRESS: • ! C TIFICATION NUMBER: PHONE NUMBER (optional): HUDSON W116 SW16- s G` d tCr CS IGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - a ',U . WAIS t aid +.#'iI i a°~ + `[t^te ami ,aci ¢sne Still test, ; in i"tipcit,t . 3i".C £ cjiwiz r.tn c <al diasc i €ption; t'fr #y,[;, Ss.r. €vr3 l-11.0t 000: 1V indi me -,,i1.,?(-ac,r ij't!._ is a r wi€.teilcc or E;t}Pnmisrvial project; MAX INIU I inirriber of he(ircto s or eo=n torcia# rise: Planned, C n eur-, the F, aJ <bilh t r;:#irt boxes. A SITE 1S SUITABLE FDH , TANK ONLY IF ALL CHEER `F, i f.:`';r1.,.,ARE rsUL OUT ;sixSH N ML {,Ow'+D +;O1`' S PLEASE w w O < bbi tow ,i.s she _.i, he; to; M pNstdo des hiptions and con-itik!nci the Plot plan, `t?t1r.S.: ;?`r-i[5:4~. i€}=:-if£C'it's`i ~,('?":.dIz1I;"i'J £t~..,s`"4.#~: y~.";tt`' i•-;St[Jt~ 7.t?E`#;5, i.E~zv'i^d" . $E)-f;c3 t' 9S (~sCt',(k,C]"t:Ej. 1 i'b SM 00101, insi r Kw '=..1's l :i i,:iirQ "We sme vourt5` ..F- t n gaj;ge At ar•3i? n, if t}llwoRI & he wi?C. k, l fire k€ M o1w i ,-a SOMIC (ova 10") 1311 Bafn Gravel "'niftier 3"i LS Wow, - Cow a ant," Fac - M. Noon" Wit VV 10Fmis syn'd San =t.j - t... Swirly Luwn 04; ~ L.€3s m mss,. sot Inain it L W. a C _c,i.r; E My Clay Lavin Wo', 1, Soa My of Nov, SONY My 1' V"'< Clay _ QMMQI~ W, to proman; Ohl This sod lest ~jtr; 111+.=', [1:„ .1. .E,c {1 sr., w y pony; ,f7{7ilu'a..bn of t.& S&i test in Me f , d r.ho r =;a h in to w F ova , system anc) a pump aP6liL;M,. M ,'.tat e submICwd , we clpvi2 4we Mania I cMi i h sa . at y i . nik „ii, ;'a£; Y ca=,, , wi j3 3 to rig, RE, T ON SOIL., 80RIN&S ; PERCOLATIoAl TEST5 1i5- PL0 T PRAM PROTECT D. ~fiV s wUS6 JJ Z 0-7L- DATE Nt tip,%y z5;T.) iP2ocU 1-ko y. Tw,v s/ o. S~ . Gcoi~ HOMESITE TESTING CO. RT- 3, O'NEiL ROAD BOB UI.I;h'L1C.; UL)SO 1, WIS,._ 54016 C57- . aZ ye2 PROP05EO HOUSE moss LIE 2,5'Fr. at MORE "o-Af . yz- TEST .,%eE.45, pRoPos D weLL M vST ii E- 5o r-r of FRo.`-~ ,gt~ TEST rg~.E~9S, o = sAt, wer plJ-3 a =EXIST/~t1 ll>ELL- X = ~F~~ ~oe'.~7'la~/f ~ = ftR~vd~ RvyF~~v o,Q s~~r~~-t l3cu►fs yo,P%z.. B M Poiar'_ ~4,-~ &A III T - ,Pr,, ~O . LE GE N D0A yr"''r fa o 00 ' ff ~ U Or. 3,0 r ~i L 'X O ILh o ~V FE•C1 CE G%,uC